THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 
Mrs.  Lottie  Brown 


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DESCRIPTION  OF  PLATE  I. 

Fie.  1. — Acute  appendicitis  with  superficial  ulceration.  The  proximal  third  (a),  apart  from 
two  or  three  pinpoint  ulcers,  is  fairly  normal.  A  similar  condition  is  noticed  in  the  distal  portion 
of  the  mucosa  (c).  The  median  portion  (b)  is  hemorrhagic  and  shows  more  extensive  ulcerations. 
The  tip  (d)  is  obliterated.  With  the  hand  lens  the  ulcers  are  found  to  occupy  the  centre  of  a 
system  of  Lieberkiihn's  crypts,  and  correspond  to  the  normal  position  of  the  lymph  nodes. 
(W.  S.  Halsted.) 

Fig.  2. — Chronic  appendicitis.  The  appendix  is  thickened,  rigid,  and  markedly  injected. 
(W.  S.  Halsted.) 

Fig.  3. — Mild  acute  catarrhal  appendicitis.  The  serous  covering  is  slightly  injected.  (T.  S. 
Cullen.) 

Fig.  4. — Typhoid  appendix.  End  of  second  week.  The  appendix  is  swollen,  erect  and 
tense,  and  hyperemic.     (W.  S.  Halsted.) 


.i  a 

■ 


THE  VERMIFORM 
APPENDIX 

AND  ITS  DISEASES 


BY 

HOWARD  A.  KELLY,  A.B.,  M.D. 

PROFESSOR   OF   GYNECOLOGY    IS   THE    JOHNS    HOPKINS    UNIVERSITY,    BALTIMORE 

AND 

E.  HURDON,  M.D. 

ASSISTANT    IN    GYNECOLOGY    IN   THE    JOHNS    HOPKINS    UNIVERSITY,    BALTIMORE 


WITH  399  ORIGINAL   ILLUSTRATIONS,  SOME 
IN   COLORS,  AND  3  LITHOGRAPHIC  PLATES 


PHILADELPHIA   AND   LONDON 

W.  B.  SAUNDERS  AND   COMPANY 

1905 


Copyright,  1905,  l>y  W.  !'•.  Saunders  \-  Company. 
Registered   al    Stationers'    Hall,  London,  England. 


Library 

<o5~ 


TO 

WILLIAM  S.  HALSTED,  M.D., 

AS    A    MARK    OF    AFFECTION    AND    ESTEEM. 


TO7017 


"Processus  vermiformis,  organon  maxima  ex  parte  secretioni 
Lnserviens  non  exigua  dignitate  sestimandus,  saepius  jam  mortalibus 
insidias  struxit,  quam  medicorum  exercitus,  more  consueto  torpe- 
factus,  hucusque  suspicabatur.  Quam  appendicular  istius  el  physio- 
logicam  e1  pathologicam  dignitatem  perpauci  solummodo  media 
agnoscentes,  organicas  illius  a  norma  aberrationcs  litteris  mandare, 
pretio  nun  indignum  fore  judicarunt." 

F.  Merling,  I.  D.  Heidelberg,  1836. 


"Der  Wurmfortsatz,  ein  so  untergeordnetes  Organ,  so  abge- 
griinzt  in  seiner  Lage  und  seinem  Bau,  so  unerklart  in  seiner  Bedeu- 
tung,  vielleicht  so  iiberfliissig  in  seiner  ganzen  Existenz,-  -und  nun 
die  Krankheiten  desselben,  und  noch  sogar  eine  einzelne  Krankheit 
init  beschrankter  Ursache!" 

A.  Voi.z,  I.  I).  Carlsrtjhe,  1846. 


"I  am  firmly  convinced  that  appendicitis  is  1 1 10  most  important 
acute  abdominal  < li-< -;i~<'  of  the  present  time,  and  that,  excluding 
certain  zymotic  diseases,  it  is  the  cause  of  more  deaths  than  any 
other  acute  abdominal  lesion." 

M.  II.  Rich  uidson. 
American  Journalofthe  Medical  Sciences,  Jan-wry,  1904. 


PREFACE. 


The  present  work  is  the  outcome  of  an  investigation  undertaken  some  years 
ago  when  I  first  began  to  notice  the  condition  of  the  appendix  in  every  ab- 
dominal operation,  an  undertaking  which  soon  grew  to  unexpected  proportions. 
The  literature  of  the  subject  is  so  extensive  that  I  fear  I  may  not  have  done 
full  justice  to  the  many  faithful  workers  in  the  field;  indeed,  even  as  the  pages 
are  passing  through  the  press,  several  valuable  articles  have  appeared  too  late 
for  recognition. 

Under  the  conviction  that  surgery  and  pathology  are  best  taught  by  demon- 
stration I  have  tried  to  parallel  the  text  with  graphic  illustrations,  and  in  a  few 
instances  the  figure  with  its  legend  stands  alone.  I  acknowledge  here  my 
indebtedness  to  Mr.  Horn,  Mr.  Brodel,  Miss  Huntington,  and  Mr.  Becker  for 
their  splendid  artistic  work;  the  enthusiasm  with  which  they  have  entered  into 
various  researches  ami  prosecuted  every  phase  of  their  work  has  greatly  en- 
hanced my  own  pleasure  and  satisfaction.  The  anatomical  chapters  were 
written  by  Mr.  Brodel  and  illustrated,  for  the  most  part,  by  Miss  Ruth  Hunt- 
ington, now  Mrs.  Brodel. 

I  will  avail  myself  of  this  opportunity  to  say  a  few  words  relative  to  the 
illustration  of  medical  works  and  the  proper  use  of  good  figures. 

The  changes  in  the  appearance  of  an  organ  brought  about  by  disease  are 
often  manifested  in  such  delicate  deviations  from  the  normal  topography  that 
it  requires  the  hand  and  eye  of  a  genuine  artist,  and  one  who  is  also  a  well- 
informed  anatomist  and  careful  pathologist,  to  represent  the  morbid  condition 
accurately.  The  sense  of  vision,  when  unaided,  often  fails  to  grasp  the  signifi- 
cance with  completeness,  and  in  such  a  case  the  true  artist  will  palpate  the 
fresh  specimen  and  then  represent  the  combined  results  of  sight  and  touch. 
The  superficial  structure  alone  is  frequently  insufficient  to  demonstrate  the 
character  of  the  specimen,  and  the  artist  must  find  means  of  exhibiting  the 
surface  relations  in  association  with  the  interior.  This  can  be  done:  (li  by 
inserting  lines,  (2)  by  cutting  away  portions  of  the  surface  and  thus  display- 
ing the  depth,  (3)  by  magnifying  the  organ  and  drawing  it  as  though  trans- 
lucent, and   (4)  by  explanatory  diagrams,  cross-sections,  etc. 

From  these  considerations  it  is  evident  that  an  intelligent  interpretation 
of  a  pathological  specimen  or  of  an  anatomical  or  clinical  demonstration  through 
the  eye  and  hand  of  a  trained  scientific  artist  must  be  vastly  superior  as  a  means 

v 


Vi  PREFACE. 

of  instruction  to  the  besl  photograph.  Yet  how  often  when  we  appeal  to  an 
illustration  for  light  on  a  difficull  text  do  we  find  a  hazy,  woolly,  milky,  or 
coarse  drawing,  which  only  succeeds  in  leaving  our  confusion  worse  con- 
founded. 

Good,  true  illustrations  area  most  valuable  handmaid  in  medical  instruc- 
tion, for  what  the  eye  of  the  studenl  has  grasped  remains,  as  old  Horace  memor- 
ably said,  indelibly  impressed  after  a  fashion  unequaled  by  the  clearest  verbal 
description.  I  would  beg  the  reader,  therefore,  not  to  be  satisfied  with  glanc- 
ing hurriedly  over  these  illustrations  and  their  legends,  returning  at  once  to 
the  text,  but  to  study  each  figure  with  care. 

The  essential  feature,  it-  centre  of  interest,  is  generally  emphasized  by  greater 
contrast  in  shading,  by  which  the  attention  of  the  observer  is  insensibly  focussed. 
The  differences  in  the  tone  value  of  the  peritoneum  over  the  small  and  large 
intestine,  and  of  the  fat.  adhesions,  etc..  are  given  in  a  manner  as  realistic  as 
is  possible  in  black  and  white  drawings.  Cysts  are  made  translucent  as  in  the 
fresh  condition.  The  method  of  making  our  originals,  whether  pen  and  ink, 
half-tone,  or  color,  has  been  selected  with  a  view  to  the  use  for  which  the  picture 
was  designed.  A  simple  topographical  relationship  is  best  shown  by  line  draw- 
ing, and  steps  in  a  operation,  half  schematically  represented,  are  done  in  pen 
and  ink.  for  anatomical  and  pathological  characteristics  where  delicate  sur- 
face structures  and  plastic  effects  are  required,  we  have  used  wash  drawings 
adapted  for  half-tone  reproduction. 

In  the  microscopic  pictures  even  the  individual  cells  have  been  drawn  with 
the  utmost  fidelity;  in  no  case  have  they  been  schematized.  Many  of  the 
pictures  will  he  best  appreciated  if  studied  with  a  low-power  hand  lens. 

I  will  here  ask  the  reader  to  correct  the  reference  on  page  93  from  p.  L83 
to  p.  186. 

One  of  the  pleasantest  parts  of  my  task  has  been  the  fact  that  I  have  been 
constantly  dependent  upon  the  good  offices  of  willing  friends. 

Dr.  Caroline  Latimer  has  been  my  faithful  aid  from  the  beginning,  revising 
the  English  of  the  manuscript  and  caring  for  it  and  forthe  proof  in  all  stages, 
besides  assisting  in  various  other  ways  too  numerous  to  mention.  Her  own 
original  labors  will  he  found  in  the  historical  chapters,  upon  which  she  has 
spent  months  of  enthusiastic  effort. 

Dr.  Henry  Christian,  one  of  our  own  graduates,  now  of  the  Boston  City 
Hospital,  has  contributed  the  chapter  on  autopsy  findings. 

Dr.  William  A.  Ford,  of  the  Johns  Hopkins  Hospital,  wrote  that  on  the 
bacteriology  of  the  appendix  and  cecum. 

My  friend,  Dr.  Harvey  Cushing,  wrote  the  section  relating  to  cocaine  anes- 
thesia in  the  chapter  on  preliminaries  to  operation. 

My  colleague.  Dr.  Hal-ted.  from  the  first  graciously  placed  the  entire  material 
of  his  large  surgical  service  at  my  disposal.  I  am  also  glad  to  acknowledge 
my  debt  to  Dr.  J.  M.  T.  Finney  and  the  other  members  of  the  surgical  staff; 


PREFACE.  VU 

the  extent  to  which  they  have  aided  me  is  in  evidence  everywhere  throughout 
the  text. 

My  associate,  Dr.  Guy  L.  Hunner.  lias  helped  me  in  revising  the  chapters 
on  treatment. 

I  am  indebted  to  Dr.  .1.  Erlanger  for  assistance  in  carrying  out  the  physi- 
ological experiments  described  in  Chap.  VIII. 

Many  friends,  notably  Dr.  Maurice  H.  Richardson,  of  Boston,  Dr.  Robert 
Abbe,  of  New  York,  and  Dr.  J.  B.  .Murphy,  of  Chicago,  have  been  most  kind 
and  patient  in  answering  numerous  and,  I  fear,  often  troublesome  letters  of 
inquiry. 

I  have  to  thank  Dr.  John  B.  Deaver,  of  Philadelphia,  for  the  use  of  his  large 
stock  of  material,  as  well  as  Dr.  A.  0.  .1.  Kelly. 

Dr.  Henry  Eisner  came  to  my  aid  in  the  chapter  on  appendicitis  in  typhoid 
fever. 

Every  one  who  has  had  to  consult  many  books  in  the  preparation  of  a 
large  work  will  realize  the  extent  of  my  obligations  to  Dr.  Robert  Fletcher,  and 
also,  ('specially,  to  the  late  Dr.  J.  E.  Merrill,  in  my  necessary  use  of  that 
monumental  foundation  of  J.  S.  Billings,  the  Surgeon-General's  Library. 

The  section  on  leucocytosis  is  not  so  comprehensive  as  1  had  intended,  but 
I  hope  to  enlarge  and  extend  it  in  a  subsequent  edition. 

In  conclusion,  let  me  thank  all  my  friends,  at  home  and  abroad,  for  speci- 
mens, notes,  and  drawings,  as  well  as  for  the  genial  atmosphere  of  cordial 
interest  with  which  they  have  invested  the  subject  from  the  beginning. 

Lastly.  I  would  call  attention  to  the  index  of  names.  It  has  been  one  of 
the  pleasantest  features  of  the  work  to  realize,  as  I  culled  these  from  the  text, 
the  truth  of  that  inspired  declaration  of  the  great  apostle  to  the  Gentiles: 
"Others  have  labored,  ye  have  entered  into  their  labors." 

Howard  A.  Kelly. 
Baltimore,  January  23,  1905. 


CONTENTS, 


CHAPTER  I. 

History 1 

From  the  First  Recorded  Case  to  the  Establishment  of  Lesions  of  the  Appen- 
dix as  Productive  of  Well-defined  Clinical  Symptoms. 

CHAPTER  II. 

History    (Continued) 10 

From  the  Distinct  Recognition  of  Lesions  in  the  Appendix  to  the  Knowl- 
edge of  Appendicitis  as  a  Surgical  Affection,  1S27-1SS6. 

CHAPTER  III. 

History    (Continued) ;!1 

The  Surgical  History  of  Diseases  of  the  Vermiform  Appendix,  1886-1904. 

CHAPTER  IV. 

Ax  \TOMY 55 

Embryology  of  the  Vermiform  Appendix.  Differentiation  between  the 
Appendix  and  the  Cecum.     Comparative  Anatomy. 

CHAPTER   V. 

Anatomy  (Continued) 89 

Folds  and  Fossae.  The  Reflection  of  the  Peritoneum  in  the  Ileocecal  Re- 
gion.    The  Inner  Surface  of  the  Ileocecal  Region  and  its  Valves. 

CHAPTER   VI. 

Anatomy  (Continued) US 

The  Position  of  the  Appendix.  The  Dimensions  of  the  Appendix.  The 
Structure  of  the  Appendix.  The  Contents  of  the  Appendix.  Obliteration 
of  the  Appendix.     Retrogression. 

CHAPTER  VII. 

A\  vn  imv  (Continued) 155 

The  Arteries  of  the  Appendix.  The  Veins  of  the  Appendix.  The  Lymph- 
atics of  the  Appendix.     The  Nerves  of  the  Appendix. 

CHAPTER   VIII. 
Physiology  100 

ix 


X  CONTENTS. 

CHAPTEE   IX. 

Natural  History L95 

Diseases  to  which  the  Appendix  is  Liable.  Acute  and  Chronic  Appendic- 
itis. Effects  of  an  Appendicitis  upon  the  Appendix  Itself.  Effects  of  an 
Appendicitis  upon  the  Structures  in  the  Neighborhood.  The  More  Re- 
mote Effects  of  an  Appendicitis. 

CHAPTEE   X. 
The  Vermiform  Appendix  at  Atttopsy 210 

Acute  Appendicitis.  Chronic  Adhesive  Appendicitis.  Chronic  <  Allitera- 
tive Appendicitis.  Cysts  of  the  Appendix.  Condition  of  Appendix  in 
1  liseasi  3  of  <  Ither  Viscera. 

CHAPTEE  XI. 
Bai  teriology 254 

CHAPTER  XII. 

Pathology 263 

Acute  Catarrhal  Appendicitis.  Acute  Diffuse  Appendicitis.  Chronic  Ul- 
cerative and  Purulent  Appendicitis. 

CHAPTEE   XIII. 

Pathology  (Continued) 302 

Peritonitis  in  General.  Localized  Peritonitis.  Spreading  or  Generalized 
Peritonitis. 

CHAPTEE   XIV. 

Pathology  (Continued) 328 

Blood  Vascular  Infection.     Lymphatic  Infect  ion. 

CHAPTEE   XV. 

Pathology  (Continued) 335 

Tuberculosis.     Actinomycosis.     Typhoid  Fever.     Amoebic  Dysentery. 

CHAPTER   XVI. 

Etiology 3.57 

Predisposing  Causes.     Exciting  Causes.     Final  Causes. 

CHAPTEE  XVII. 

Clinical  History 385 

Symptoms.     I  implications. 

CHAPTEE  XVIII. 

Diagnosis *"" 

Diagnosis.     Differentia]  Diagnosis. 

CHAPTER   XIX. 

Appendicitis  in  Tythoid  Fever -131 

History.     Etiology.     Diagnosis.      Treatment. 


CONTENTS.  XI 

CHAPTER  XX. 

Appendicitis  in  the  Child 450 

History.     Etiology.    Symptomatology  and  Diagnosis.    Treatment. 

CHAPTER   XXL 
Typhlitis 485 

CHAPTER  XXII. 

General  Considerations  Regarding  (  (peration 4'.U 

Introductory.  Indications  for  Operation.  Immediate  Operation.  Inter- 
mediate Operation.     Late  Operation.     Interval  Operation. 

CHAPTER  XXIII. 

Preliminaries  to  Operation" 510 

-Medical  Treatment.  Preparations  for  Operation.  Nitrous  Oxid  Anesthe- 
sia.    Cocaine  Anesthesia. 

CHAPTER   XXIV. 
Incisions s 523 

CHAPTER  XXV. 

Removal  of  the  Appendix 541 1 

Exposure  of  the  Appendix.  Typical  ( Operations  for  Removal  of  the  Appen- 
dix. Atypical  Operations  for  Removal  of  the  Appendix.  Meckel's  Diver- 
ticulum. 

CHAPTER  XXVI. 
Abscess  in  the  Neighborhood  of  the   Appendix,  or  Suppurative  Peri- 
appendicitis    603 

Removal  of  the  Appendix  in  Suppurative  Cases.  Treatment  of  Abscess. 
Treatment  of  Abscess  in  Special  Cases.     Pelvic  Appendiceal  Abscess. 

CHAPTER  XXVII. 

Peritonitis 633 

Progressive  Purulent  Peritonitis.     Diffuse  Purulent  Peritonitis. 

CHAPTER  XXVIII. 
Care  of  Patient  lfter  Operation  and  Post-operative  Sequelje 655 

CHAPTER  XXIX. 

Relation  between  Appendicitis  and  Gynecological  Affections 698 

General  Considerations.     Diagnosis.     Treatment. 

CHAPTER  XXX. 
Relations  of  Appendicitis  to  Pregnancy,  Labor,  \ni>  the  Puerperium.  .  .   720 

CHAPTER   XXXI. 

Neoplasms 7.',7 

Benign  Tumors.     Malignant  Tumors. 


Xll  CONTENTS. 

CHAPTER   XXXII. 

Clinical  History  of  the  Specifn    Infections 7t;i 

Tuberculosis.    Actinomycosis.    Amoebic  Dysentery. 

CHAPTER  XXXin. 

Operative  Treatment  of  Neoplasms  and  Specifh    Infections 772 

Disease  Limited  to  the  Appendix.     Disease  in  the  Ileocecal  Region. 

CHAPTER   XXXIV. 

Hernia  of  the  Appendix 786 

CHAPTER  XXXV. 

Mi.liii  o-leo \i.  Aspe<  rs  of  Appendicitis 794 


LIST  OF  ILLUSTRATIONS. 


FIG.  _  PAGE 

1.  Human  embryo  (six  weeks).     Lateral  and  anterior  views  with  umbilical  cord  cut  open  .  56 

2.  Human  embryo  (seven  weeks).     Lateral  view  with  umbilical  cord  cut  open 57 

3.  Same  embryo  as  in  Fig.  2.     Anterior  view  of  intestinal  loops  within  the  cord 57 

4.  Human  embryo  (seven  weeks).     Showing;  coil  of  intestines  within  the  opened  cord  and 

the  cecum  with  the  transient  appendix 58 

5.  Human  embryo  (seven  and  a  half  weeks).     Showing  the  receding  of  the  cecum  from  the 

cord  into  the  body 59 

6.  Human  embryo  (eight  weeks).     Showing  the  last  stage  in  the  receding  of  the  intestinal 

coils  from  the  cord  into  the  body 59 

7.  Human  embryo  (eight  weeks).     Differentiation  between  the  cecum  and  appendix 60 

8.  Human  embryo  (nine  weeks).     Showing  the  intestines  entirely  within  the  body 60 

9  and  10.   Human  embryos  (nine  to  ten  weeks).     Cecum  and  appendix  near  the  median 

line    61 

11.  Human  embryo  (ten  weeks).     Cecum  ami  appendix  in  the  right  hypochondriac  region.  .  61 

12.  Human  embryo  (eleven  weeks).     The  ileocecal  apparatus  near  the  median  line.  .  61 

13.  Human  embryo  (thirteen  weeks).     Cecum  and  appendix  anterior  to  the  right  kidney.  .  62 

14.  Human  embryo  (three  months).     Cecum  and  appendix  anterior  to  the  right  kidney.  .  .  63 

15.  Human  embryo  (three  months).     Small  intestine  removed,  showing  ileocecal  apparatus 

anterior  to  the  right  kidney 63 

16.  Human  embryo  (three  months).     Transverse  section  through  lower  half  of  body 64 

17.  Human  embryo  (fourteen  weeks).     Appendix  in  subhepatic  position 65 

18.  Human  embryo  (three  to  four  months).     Beginning  descent  of  cecum 65 

19.  Human  fetus  (four  months).     Showing  relative  position  of  cecum 66 

20.  Same  as  preceding  with  large  part  of  intestines  removed 66 

21.  Human  fetus  (four  months).      Lower  right-hand  corner  of  abdominal  cavity 67 

22.  Human  fetus  (four  to  five  months).     Showing  body  open  with  appendix  and  other  organs 

in  situ 68 

23.  Same  as  preceding  with  most  of  I  hi'  small  intestine  removed      68 

24.  Human  fetus  (five  months).      Somewhat  lateral  view  of  the  abdominal  vi.-cera  in  situ  69 

25.  Appendix  region  of  fetus  shown  in  preceding  figure 69 

26.  Human  fetus  (six  to  seven  months).     Abdominal  cavity  open  with  ileum  removed  70 

27.  New-born  babe.      Right-hand  corner  of  abdominal  cavity        71 

28.  Development  of  the  ileocecal  apparatus  from  the  age  of  live  to  seven  weeks 72 

29.  Development  of  the  ileocecal  apparatus  between  the  ages  of  eight  and  twelve  weeks  73 

30.  Development  of  the  ileocecal  apparatus  between  the  ages  of  three  and  seven  months  74 

31.  Development  of  the  appendix  from  the  newborn  to  the  adult    >tage    75 

32.  Primitive  type  of  ileocolic  region      80 

33.  34,  35,   36,  37.  and  3.8.   Symmetrical  form  of  cecum Sit  and  81 

39,  40,  41,  42,  and  43.  Asymmetrical  development  of  single  cecal  pouches si  and  82 

1 1  to  53.    Rectangular  ileocolic  junction 82,   83,   and  8  t 

54  to  58.  Cecal    apparatus    combined    with    structural    mollifications    of    adjacent    portion 

of  colon si   and  85 

59.  Absence  of  cecal  pouch 85 

xiii 


xiv  LIST   OF   ILLUSTRATIONS. 

FIG.  PAGE 

60.  Cecal  apparatus  in  Hyrax 85 

61.  Anterior  view  of  ileocecal  region  of  Vteles     86 

62.  Anterior  and  posterior  views  of  ileocecal  region  of  Mycetes  fuscus      86 

63.  Anterior  and  posterior  views  of  ileocecal  region  of  Mangabey  monkey 87 

64.  Anterior  and  posterior  views  of  ileocecal  region  of  Gibbon S7 

65.  Anterior  and  posterior  views  of  ileocecal  region  of  kangaroo 87 

66.  Folds  and  fossa'  of  the  il secal  region  90 

07.  Development  of  the  vascular  folds  (usual  form) 95 

68.  Development    of   the    \  ascular  folds.      Anterior  mesappendix 97 

69.  Anterior  position  of  the  mesappendix        98 

71).  I  levelopraent  of  the  vascular  folds.     Mesappendix  attached  to.lower  border  of  ileum  100 

71    The  eight  most  frequent  types  of  peritoneal  reflection  of  the  ileocecal  region    107 

72,    7ii,    71,    75,    70,    77,    and    78.    Most     striking    types    of    tntra-peritonea]    and    extra- 
peritoneal   appendices ION   and    1(1!) 

79.  Valves  of  the  ileocecal  region Ill 

80.  Appearance  of  the  appendical  orifice  where  the  ceco-appendical  angle  measured  20  de- 

grees      112 

81.  Appearance  of  the  appendical  orifice  where  the  ceco-appendical  angle  measured  30  <le- 

grees        112 

82.  Appendical  orifice  in  connection  with  a  ceco-appendical  angle  of  42  degrees 113 

83.  Appendical  orifice  in  connection  with  a  ceco-appendical  angle  of  00  degrees      113 

84.  Ceco-appendical  angle  of  60  degrees 114 

85.  Ceco-appendical  angle  of  90  degrees 115 

so.   Exceptioual  form  of  appendical  orifice  in  a  case  where  the  appendico-cecal  orifice  meas- 
ured only  12  degrees 116 

87.  Diagram  showing  various  places  on  the  surface  of  the  cecum  from  which  the  appendix 

may  take  its  origin 119 

88.  Fetal  type  of  appendix 119 

89.  Persistent  fetal  type  of  cecum  anil  appendix    in  an  adult    120 

90.  91.  92,  and   93.    Appendix  arising  at    point    ici   In    Fig.  N7         121 

91.  Appendix  arising  from  the  anterior  and  median  extremities  of  the  cecum. . ,  121 

95.  Appendix  arising  from  the  interior  portion  of   the  cecum  at  point  (b)  in   Fig.  87.     ...  122 

96.  Point  of  appendical  origin  at  (f)  in    Fig.  N7                122 

97.  Abnormal   position   of  appendix   and  abnormal  arrangement    of    its  blood-supply  122 

98.  Point    of  appendical  origin  at   (d)  in    Fig.   NT    123 

99.  Point  of  appendical  origin  at  (e)  in  Fig.  87 123 

10(1.  1  liagrams  showing  the  changes  in  the  topography  of  the  ileocecal  apparatus  due  to  dis- 
tention of  the  colon  in  cases  of    non-adherent   cecum    12.r> 

101.  Diagrams  showing  the   various  directions    in   which  an   appendix   may   point 127 

102.  Normal    position    of  the   ileocecal    apparatus 128 

103.  Diagram  showing  the  positions  of    moderate  displacement   of  the  appendix 129 

101.  Diagram  showing  the  excursions   possible   to  an    ileocecal    apparatus   with   a    long  and 

movable  mesentery 120 

105.  Position  of  cecum  and  large  intestine  affected  by  ileo-cecal  apparatus  being  fixed  in  the 

position  it  occupied  during  eighth  week  of  early  embryonic  life 130 

100  Cecum    fixed    on    left    side   of    body 131 

107.  Cecum  arrested  in  the  subhepatic  position  132 

IDS.  Cecum   arrested   in   the  subhepatic    position    anil    turned    upward 133 

109.  Cecum  in  the  subhepatic  position  and    pointing  laterally 134 

1  K).  Transposition  of   the  abdominal  viscera 135 

111.  Appendix  measuring  21.5  cm.   (S<   in.)  in   length 137 

112.  Section  through  normal   appendix 140 

113.  Ileocecal  region   in   a  woman   possessing  an   abnormal   amount  of    fat 142 

114.  Longitudinal  section  through  the  distal  portion  of  a  normal  appendix  and   its  mesen- 

teriolum 142 


LIST    OF    ILLUSTRATIONS.  XV 

FIG.  .  P*«E 

115.  Portion  of  the  mucous  membrane  in  a  young  individual  showing  arrangement  of  lymph 

nodes  on  surface L45 

116.  Surface  of  the  mucous  membrane  of   an  appendix  magnified  6.5  times 145 

117.  Portion  of  normal  mucous  membrane  of   an  appendix  magnified  150  times 147 

118.  Blood-vessels  of  the  ileocecal    region 157 

119.  A  complete  injection  of  the  appendical  bl L-vessels  in  a  seven   months  fetus 159 

120.  Reconstruction  of  the  blood-supply  of   the  appendix facing  160 

121.  Portion  of  mucosa  injected  and  cleared  to  show  the  blood-vessels    facing  160 

122  to  138.  Types  of  I  he  appendical  arterial  circulation 162-166 

139.  Veins  of  the  appendix  and  their  relation  to  the  portal  and  systemic  circulation  .  .facing  168 

140.  Reconstruction  of  the  lymphatics  of  appendix facing  170 

141.  Lymphatic  circulation  of  the  ileocecal  region.     Anterior  view 175 

142.  Posterior  view  of  the  ileocecal  region  showing  the  main  lymph  trunks  and  their  rela- 

tion to  the  ileocolic  chain  of  glands    177 

143.  144,  145,  and  14ii.  Types  of  the  appendical  lymphatic  circulation 170  and  181 

147.  Graphic  tracing  showing  movements  of   the  appendix 193 

14S.  Various  kinks  and  bends  of   the  appendix 200 

149.  Case  of  appendix  covered  in  by  dense  sheet  of  adhesions 201 

150.  Appendix  passed  by  the  rectum 203 

151.  Inflammatory  residual  mass  at  the  tip  of  the  appendix  attached  to  the  ileum  at  a  dis- 

tance from  the  valve 205 

152.  Senile  atrophy  of  cecum   in  a  man  eighty-six   years    old 224 

153.  Thrombus  in  the   portal  vein 232 

154.  Portal  infection 242 

155.  Acute  suppurative  interstitial  hepatitis  due  to  portal  infection 243 

156.  Suppurative  thrombo-phlebitis  of  the  mesenteric  veins  with  multiple  abscess  in  the 

liver  following  appendicitis facing  245 

157.  Section  from  the  specimen  represented  in   Fig.  3,  Plate  1    264 

158.  Deposit  of  pigment  in  the  mucosa  of  the  appendix 265 

159.  Acute  appendicitis.     Hemorrhagic  infiltration  of  mucosa 267 

160.  Acutely  inflamed  appendix  showing  greatly  dilated  blood-vessels 267 

161.  Acute  appendicitis.     Inflammation  limited  to  the  distal  half  of  the  appendix 267 

162.  Acute  appendicitis.     Appendix  lined  with  necrotic  material 269 

163.  Appendix  almost  totally  gangrenous 269 

164.  Total  gangrene  of  interior  of  the  appendix 271 

165.  Acute  appendicitis  with  thickened  hemorrhagic  mesappendix 271 

166.  Acute  diffuse  appendicitis 272 

167.  Higher  magnification  of  the  margin  of  ulcer  seen  in  the  preceding  figure 273 

168.  Acute  appendicitis  with  severe  lymphangitis '-'71 

169.  Thrombus  in  a  lymph  sinus 275 

170.  Perforative  appendicitis 276 

171.  Acute  appendicitis.     Showing  protrusions   of  mucous  membrane 277 

172.  Chronic  appendicitis  with  anemic  bulbous  tip  containing  soft  fecal  mass 279 

173.  Chronic  appendicitis.     Mucous  membrane  forming  distinct   polyp 280 

174.  Chronic  appendicitis.     Showing  changes  in  submucosa 280 

175.  Chronic  appendicitis  with  complete  stricture  in  the  middle    2S0 

17li.  Section  from  the  preceding  specimen 281 

177.  Section  from  the  appendix  shown  in  Fig.  2,   Plate  III 282 

178.  Section  from  the  preceding  case  showing  atypical  glands  and  mucoid  degeneration      .  283 

179.  Ubliterative  endarteritis  in  the  mesappendix 284 

180.  Empyema  of  the  appendix 2S6 

181.  Chronic  suppurative  appendicitis  with  obliterated  lumen  ami  a  ruptured  pus  sac  be- 

yond it 2m; 

182.  Multiple  strictures   in  the  appendix 287 

183.  Kink  and  stricture  produced  by  adhesions  in  a  case  of  chronic  appendicitis 2s7 


XVI  LIST   OF   ILLUSTRATIONS. 

no,  i-Ai.i 

184.  Cystic  appendix  with  the  proximal  end  protruding  into  the  cecum 288 

is.").  Cystic  . I i — t < -i 1 1 1- >i i  of  the  lower  three-fourths  of  the  appendix  due  to  stricture  of  the 

canal 289 

186.  An   appendix  showing  a  single  cyst  and  an   obliterated  withered  extremity 289 

ls7.  The  same  appendix  when  removed  six  years  later 290 

188.  Cystic  appendix 290 

189  Section  from  the  preceding  specimen  of  cystic  appendix 291 

190.  Hypertrophied  appendix  with  obliterated  lumen   , . ,  293 

191.  Atrophied  appendix  with  obliterated  lumen 203 

192.  Chronic  appendicitis  with  stricture 294 

193.  Obliterated  appendix  covered  in  with  adhesions  and  hidden  behind  the  ileum         .  294 

194.  Section  from  specimen  shown  in  Fig.   191 296 

19">.  Obliteration  of  the  lower  two-thirds  of  the  appendix    297 

196  Appendix  containing  spherical  concretions     299 

197.  Mucous  membrane  showing  impression  of  the  enterolith  seen  in  Fig.  232 301 

19V  Acutely  inflamed  appendix  with  the  omentum  adherent  to  a  point  of  threatened  per- 
foration   308 

199.  Appendix  rolled  up  in  the  omentum.  ...  309 

200.  Encysted  peritonitis  surrounding  the  tip  of  the  appendix       310 

201.  Encysted  peritonitis  of  tubercular  origin  311 

202.  Chronic  appendicitis  showing  the  appendix  twisted  half  round  upon  its  axis  325 

203.  Pocketed  appendix  resulting  from  old  localized  peritonitis     326 

204.  Tuberculosis  of  the  appendix 337 

205.  Hyperplastic  tuberculosis  of  the  appendix 338 

206.  Section  through  the  wall  of  the  appendix  represented  in  Fig.  205 facing  338 

2i)7.  Higher  magnification  of  the  superficial  tubercles  seen  in  the  preceding  section   .    .  339 

208.  Actinomycosis  of  the  appendix 345 

209.  Actinomycosis  of  the  appendix.     Section  through  median  portion  of  the  organ.  345 

210.  Actinomycosis  of  the  appendix.     Section  through  the  wall  of  the  organ  at  junction 

of  the  submucosa  and  circular  muscular  coats  347 

211.  Thrombosed  vessels  in  the  appendix  in  a  case  of  typhoid  fever     349 

212.  Typhoid  ulceration  of  the  appendix 350 

213.  Section  from  the  base  of  the  ulcer  seen  in  Fig.  212 350 

214.  Higher  magnification  of  large  phagocyte-  350 

215.  Typhoid   appendix,   eleventh  week   of  the  disease  351 

216.  Typhoid  appendix.     Section  from   Fig.  215 351 

217.  Amoebic  dysentery.      Appendix  bent   at   right  angle-  and  held  in  this  position  by  firm 

adhesions   353 

21S.  Subacute  appendicitis  associated  with  the  presence  of  two  concretions    362 

219.  Appendix  containing  enteroliths  resembling  gall-tones 363 

220.  Appendix  containing  a  calculus,  probably  a  gall-stone 364 

221.  Appendix  containing  two  small  seeds.  364 

222.  Appendix  perforated  by  a  pin 368 

223.  Appendix  adherent  to  abdominal  walls  following  discharge  of  pin 369 

224.  Appendix  perforated  by  a  four-inch  shawl  pin 370 

225.  Pin   shown   in    fig.  224,  after  removal.      Head   buried   in   a   C retion 371 

226.  Appendix  containing  common  pin 371 

227.  Bullet  forming  nucleus  oi  a  concretion 372 

22s.  Appendix  containing  bullet ...  373 

229.  Appendix  containing  shot  and  grape-seed  373 

230.  Fish-fin  in  the  appendix 374 

231.  Appendix  containing  a  lumbricus 376 

232.  Foreign  bodies  and  concretions  in  the  appendix  379 

233.  Piezometer 411 

234.  Method  of  using  the  piezometer 412 


LIST    OF    ILLUSTRATIONS.  XV11 

FIG.  PAGE 

235.  Funnel-shaped  orifice  in  acute  perforative  appendicitis  occurring  in  a  girl  three  and  a 

half  years  of  age 452 

236.  Intestinal  needle  with  split   eve 515 

237.  Delicate,  light,  curved  mouse-toothed  forceps 516 

238.  Showing  tin-  muscular  and  tendinous  structures  involved  in  making  the  various  in- 

cisii  >ns 525 

239.  Representing  the  principal  arterial  and  nerve-trunks  of  the  right  abdominal  wall      .   527 

240.  Cadaver  showing  location  of  various  incisions  for  removal  of  the  appendix,  in  right 

lower  quadrant  of  abdomen 529 

241.  McBumey's  incision  (I) 530 

242.  McBumey's  incision   (II) 531 

243.  McBumey's  incision  (III) 532 

244.  McBumey's  incision  (IV) 533 

245.  Finney's  incision 534 

240.  Incision  in  semilunar  line  I  Battle  i 535 

247.  Incision  in  semilunar  line,  opening  rectus  sheath 536 

248.  Incision  in  semilunar  line.     Division  of  strata  of  abdominal  wall 537 

249.  Appendix  concealed   behind  cecum    and  flexed  on  itself  with  its  tip  concealed  in  a 

retro-peritoneal  pocket 541 

250.  Showing  a  misleading  constricting  band  simulating  the  anterior  tenia  muscle 542 

251.  Appendix  adherent  across  the  common  iliac  artery 543 

252.  Embryonic  displacement  of  appendix,  which  Is  bound  down  by  adhesions  to  the  pre- 

renal peritoneum 544 

253.  The  cecum  and  colon  lifted,  showing  the  high  retrocolic  appendix  kinked  and  wrapped 

in  adhesions 545 

254.  Showing  the  appendix  completely  concealed  by  the  cecum  and  colon .546 

255.  Showing  the  appendix  buried  in  a  retro-mesenteric  pocket 547 

256.  Retro-mesocolic  appendix  with  tip  buried  in  adhesions 548 

257.  Appendix  lying  in  a  large-mouthed  retrocecal  pocket 549 

258.  An  antero-posterior  section  of  the  preceding 550 

259.  A  collective  picture  showing  the  various  points  of  attachment  of  the   appendix  to 

structures  in  the  abdomen 551 

260.  The  commonest  type  of  circulation  at  the  appendico-cecal  angle 552 

261.  Normal  type  of  circulation  in  non-adherent   appendix 552 

262.  The  appendical  and  cecal  circulatory  systems  entirely  disassociated 553 

263.  Cecal  vessels  supplying  the  root  of  the  appendix 553 

264.  Broad  arterial  anastomosis  in  the  mesappendix 554 

265.  Showing  method  of  controlling  circulation  when  the  mesappendix  is  bound  down.    .  554 

266.  Showing  the  control  of  the  vessels  in  tin-  case  of  an  appendix  adherent  to  the  outer  sur- 

face of  the  colon 555 

267.  Diagram  after  Edebohls   showing  the  danger  of   burying  the  exposed  mucous   mem- 

brane of  the  stump 555 

268.  A  simple  widely  used  method  of  exsection  of  the  appendix,  1 556 

269.  II,  The  stump  of  the  appendix  grasped  with  forceps  and  thrust  into  the  bowel    .  556 

270.  Ill,  The  circular  suture  tightened  and  tied  while  the  forceps  is  withdrawn 557 

271.  IV,  Final  step  showing  the  placing  of  the  mattress  sutures  over  the  circular  sutures  557 

272.  Finney's  method  of  freeing  the  amputation  area  of  all  its  contents  and  of  the  mucosa  558 

273.  Halsted's  three-clamp  method  of  removal.  I ^'^ 

274.  Halsted's  three-clamp  method,  II 560 

275.  Beck's  method  of  dealing  with  the  stump 560 

27ti.    Fowler's  cuff  method   (I) 561 

277.  fowler's  cuff  method  (II  and  III) 562 

278.  Fowler's  cuff  method  (IV) 563 

279.  Dawbarn's  method  of  inverting  the  stump 564 

280.  Edebohls'  method  of  inverting  the  whole  unopened  appendix 565 

1* 


wii'i  list  OF   ii.i.r-ri:  \  nONS. 

Hi,  PAGE 

281  Edebohls'  method  of  inversion  completed 566 

282.  Deaver"s  method  of  amputating  the  appendix  flush  with  the  cecum 567 

283  I  kiwnes'  method  of  removing  the  appendix 568 

L'M  Kelly's  crushing  forceps  with  groove  for  contacl  with  cautery  point  for  cooking  the 

stump  of  the  appendix 569 

285.  Kelly's  method  of  removing  the  appendix  (I) .  569 

286.  Kelly's  method  (II)     570 

287.  Kelly's  method  completed  (III)       570 

2ss  I   i  ilium's  method  of  removing  the  appendix 571 

289.  Lennander's  method  of  removing  the  appendix  (I) 572 

290.  Lennander's  method  ill  and  IIIi 573 

291.  Lennander's  method  (IV) 573 

292.  Cystic  appendix  attached  to  the  omentum 574 

293.  Enlarged  inflamed  appendix  completely  hidden  by  newly-formed  adhesions  576 

294.  Method  of  stripping  out  the  mucosa  and  submucosa  in  the  case  of  a  densely  adherent 

appendix  (I) 577 

295.  Method  of  ^trit.]iiTis  oul  the  appendix  (II)   577 

290.  Method  of. stripping  out  the  appendix    III  I 578 

297.  Method  of  incising  the  dorsum  of  the  appendix  and  removing  it  by  traction 579 

298.  Showing  the  inner  coats  "f  the  appendix  removed  l>y  stripping 580 

299.  Specimen  of  abnormally  long  appendix,  of  which  the  proximate  pari  was  removed 

in  this  way.  580 

300.  Retrocolic  appendix  so  buried  in  adhesions  that  removal  in  the  usual  manner  is  dan- 

gerous to  the  coats  of  the  cecum  581 

301.  Method  of  removing  retrocolic  appendix  (I)     582 

302.  Method  of  removing  retrocolic  appendix  (II) .  583 

303.  Showing  such  an  appendix  in  section    584 

304.  Appendix  completely  concealed  under  adherent  cecum 585 

305.  Appendix  lying  retro-peritoneally  with  it-  tip  buried  in  the  substance  of  the  psoas 

muscle 586 

306.  Appendix  densely  adherent  to  the  caput  coli  and  ileum 590 

307.  The  same  as  the  preceding,  showing  the  thickened  tip  above  and  the  perforation  near 

the  base 591 

308.  Fistula  from  the  appendix  out.,  the  Burface  of  the  abdomen 592 

■    Diagram  of  the  most  primitive  form  of  Meckel'-  diverticulum 595 

310.  Diagram  of  a  more  advanced  form  of  diverticulum 595 

311.  Diagram  of  a  -lill  more  advanced  form  of  diverticulum 596 

312.  Usual  form  of  Meckel's  diverticulum 596 

313.  Unusually  narrow  Meckel'-  diverticulum,  easily  mi-taken  for  an  appendix.  597 
:>11.  Me.kel'-  diverticulum  with  several  small  distention  diverticula  at  its  distal  portion  598 

315.  Large  Meckel's  diverticulum.  70  cm.  from  the  valve    600 

316.  A  composite  picture  showing  the  various  positions  in  which  an  appendical  abscess  may 

lie ." 604 

317.  Location  of  various  small  abscesses  in  the  ileocolic  region 605 

:'.is.  Appendix  coiled  on  itself  in  spiral  form,  below  and  in  front  of  the  ileocecal  junction.   606 

319.  Appendix  buried  under  two  layer-  of  peritoneal  folds  forming  two  pocket-  ....   607 

320.  Mikulicz's  natural  barriers  to  the  spread  of  infection  608 

321.  Abdomen  showing  the  three  major  fossa;,  right,  left,  and  pelvic. 609 

322.  Frozen  section        -  showing  interior  of  cecum  and  colon  with  cecal  opening  into 

appendix  and  section  of  appendix  and  mesappendix 610 

323.  Horizontal  section  just  above  the  insertion  of  the  appendix,  showing  the  relation  of 

the  appendix  and  the  mesappendix  to  the  fascia;  and  muscles  of  the  posterior 
abdominal  wall ''11 

324.  Weir-  incision  for  enlarging  the  McBurney  opening  without  dividing  the  muscles..   615 

325.  Doughty's  method  for  securing  more  room  in  abscess  and  other  difficult  cases 616 


LIST    OF    ILLUSTRATIONS.  MX 

Fir,.  PAGB 

320.  Showing  the  wide  area  of  exposure  to  the  peritoneum  given  by  Doughty's  method    t •  1 » > 

327.  Showing  the  complete  closure  of  the  wound  by  Doughty's  method  and  the  relations 

of  the  lines  of  sutures 017 

328.  Diagram  showing  the  method  of  approaching  an  abscess  by  the  extra-peritoneal  route  017 

329.  Method  of  approaching  an  abscess  by  the  transperitoneal  route ''17 

330.  Showing  the  various  sites  at  which  abscesses  are  more  commonly  found.    .    .  018 

331.  Unusual  location  of  the  appendix  high  up  to  the  inner  side  of  the  ascending  colon  and 

covered  by  omentum 621 

332.  Pin-point  perforation  at  the  tip  of  the  appendix 021 

333.  Method  of  exposing  ami  evacuating  ah-cess  through  an  incision  in  the  median  or  right 

semilunar  line 023 

334.  Showing  the  hand  within  the  abdomen  guiding  and  controlling  the  forceps  in  the  act 

of  opening  the  abscess  through  the  lateral  incision 624 

335.  Appendix  and  cecum  wrapped  in  omental  adhesions  625 

336.  Gangrenous  abscess  and  perforation  of  the  appendix  completely  enveloped  and  pro- 

tected from  the  peritoneal  cavity  l>y  the  omentum 026 

337.  Large  retro-peritoneal  abscess  in  a  girl  ten  years  old 629 

338.  Tip  of  the  appendix  lost  in  a  pool  of  pus  filling  the  pelvis  and  walled  in  by  adherent 

intestine 630 

339.  Perforation  near  the  root  of  the  appendix  in  a  patient  dying  of  peritonitis  634 

340.  Elsberg's  operation  for  subphrenic  abscess,  showing  skin  incision  039 

341.  Resection  of  ninth  and  tenth  ril >~  in  subphrenic  abscess         640 

342.  Subphrenic  abscess  aspirated  through  the  diaphragm  and  below  the  pleural  reflection  641 

343.  Fowler's  method  of  drainage,  in  diffuse  purulent  peritonitis nil 

344.  Self-retaining  retractor 646 

345.  Method  of  washing  out  the  abdomen  when  full  of  pus  by  means  of  a  long  metal  tube 

with  spray  attachment 648 

340.   Method  of  using  the  irrigator  to  push  forward  the  peritoneum  in  the  abdominal  wall 

when  making  a  left  lumbar  incision  for  drainage  in  abdominal  pyemia  649 

347.  Showing  direction  of  current  from  the  adjacent  portions  of  the  abdominal  cavity  to- 

ward the  various  drainage  openings 050 

348.  Retrocecal  abscess  found  at  st nd  operation  two  year-  after  removal  of  the  appendix  665 

349.  Same  as  preceding,  showing  abscess  exposed  behind  cecum 666 

350.  Intestinal  obstruction  following  operation  for  appendicitis  due  to  omental  adhesion- 

over  stump  of  appendix 689 

351.  Showing  large  hernia  following  incision  in  the  semilunar  line  for  appendicitis  .    .   695 

352.  Operation  for  hernia  showing  rectus  dovetailed,  between  the  broad  abdominal  muscle-  696 

353.  Showing  in   detail   the  method   of  drawing  rectus   between   muscles 697 

354.  Inflamed  appendix  adherent   to  a  tubo-ovarian  abscess    703 

355.  Obliterated  appendix  adherent  to  a  chronic  tubo-ovarian  inflammatory  mass  794 

356.  Tip  of  appendix  adherent  to  -mall  dermoid  cyst  of  left  side  706 

357.  Appendix  densely  adherent  to  fibroid  tumor  undergoing  sarcomatous  degeneration       7ns 

358.  Appendix  adherent  to  right  broad  ligament  in  a  right  extra-uterine  pregnancy  .    709 

359.  Detailed  study  of  the  preceding  figure        709 

360.  Long  appendix  adherent   by  it-  tip  to  suspensory  ligament  attaching  litem-  to  ante- 

rior abdominal   wall 720 

361.  Extensive  involvement  of  the  appendix  in  a  tubo-ovarian  abscess  of  the  right   side. 

Method  of  removing  appendix      724 

302.  Method  of  removing  an  adherent  appendico-tubo-ovarian  ma--  in  reverse  order  to 

thai  shown  in  preceding  figure 725 

363.  Tubo-ovarian  abscess.     Peri-appendicitis 720 

364.  Distal  portion  of  appendix  adherent  to  the  broad  ligament   in   a  ca-e  of  large  multi- 

locular  ovarian  cyst 727 

365.  Appendix  adherent  to  uterine  tube  and  ovary  in  the  midst  of  extensive  adhesions       728 

366.  Appendix  adherent  to  the  pregnant  rudimentary  horn 731 


X\  LIST  OF   ILLUSTRATIONS. 

Mi  PAOE 

367.  Polypoid  mass  projecting  from  the  cecal  end  of  the  appendix...  7:ts 

:;r,s  Polyp  in  the  appendix  removed  six  weeks  after  an  attack  of  appendicitis 738 

369  Parasitic  myoma  adherent  to  the  appendix Tin 

370.  Fibroma  of  the  appendix.     Anterior  view 711 

371.  Fibroma  of  the  appendix.     Posterior  view 742 

372.  Fibroma  of  the  appendix,  section  from  preceding  case 743 

.'i?:i.  Carcinoma  of  the  appendix  causing  acute  perforative  appendicitis                       .  74i> 

374.  Primary  carcinoma  limited  to  tip  of  the  appendix,  the  remainder  of  which  is  normal  717 

.'i7.">.  Same  as  preceding,  showing  constriction  proximal  to  growth 747 

376.  ( 'a  rein  on  i, a  of  the  appendix 717 

:i77.  Section  from  the  case  shown  in  preceding  figure 7  is 

378.  \  small  area  from  Fig.  :i77 749 

379.  Colloid  carcinoma  of  the  appendix  discovered  at  autopsy     7.50 

380  Section  from  the  preceding  case  of  colloid  carcinoma .  751 

381.  Invasion  of  the  tip  of  the  appendix  by  contiguity  from  a  papillary  carcinoma  of  the 

ovary 756 

382  Sarcoma  of  the  appendix  involving  the  adjacent  portion  of  the  cecum       757 

383.  Section  from  the  preceding  case  of  sarcoma  showing  diffuse  infiltration  of  the  walls 

of  the  appendix  with  sarcoma  cells 758 

384.  Higher  magnification  of  Fig.  383 759 

:is."i.  peritoneal  tuberculosis  involving  the  appendix  which  has  become  partly  twisted  on  its 

axis 7(12 

386.  Inflammatory  thickening  with  tuberculous  stricture  of  the  ascending  colon  followed 

by  perforation   of  I  he  colon                     766 

387.  Cross-section  of  the  preceding 766 

388.  Tuberculosis  of  the  cecum  and  appendix  extending  up  into  the  colon 767 

389.  Carcinoma  of  the  ileocecal  valve  extending  into  cecum  and  closely  simulating  appen- 

dicitis                             ~~~ 

390  Mesenteric  ruffle  showing  the  groups  and  disposition  of  the  coils  of  the  ileum  77ft 

391.  Anastomosis  of  a  loop  of  the  ileum  into  the  transverse  colon       780 

392.  McGraw's  elastic  ligature  for  lateral  anastomosis       781 

393.  Lateral  anastomosis  after  Halsted  782 

394.  Steps  in  Council's  operation  for  intestinal  anastomosis  by  suture  within  the  bowel  784 
39S  Appendix,  with  cecum,  and  beginning  of  ascending  colon  in  a  left  inguinal  hernia  788 
306.  Appendix,   cecum,   small   intestine,   and   omentum   adherent    in   an   umbilical  hernia  789 

3!i7.  Appendix  in  a  right  inguinal  hernia 790 

;,'.iv  i  langrenous  appendix  in  a  right  femoral  hernia 7'.i2 

399.  Case  in  which  acute  appendicitis  and  death  followed  severe  muscular  strain 809 


LIST  OF  PLATES. 


Plate  I Frontispii  1 1 

Fig.  1.  Acute  appendicitis  with  superficial  ulceration. 

2.  Chronic  appendicitis. 

3.  Mild  acute  catarrhal  appendicitis. 
i.   Typhoid  appendix. 

Plate  II facing  page  270 

Fig.  1.   Acute  appendicitis.      Xo  adhesions. 

12.   Acute  appendicitis.      Distal  third  bent  at  an  obtuse  angle  l>y  a  hand  of  adhesions. 
3.  Gangrenous  appendicitis. 

Plate  III facing  pagt  282 

Fig.  1.   Acute  appendicitis.      Foci  of  suppuration  visible. 

2.  Chronic  appendicitis. 

3.  Enteroliths  in  the  appendix. 

4.  Mild  subacute  appendicitis. 


XXI 


THE  VERMIFORM  APPENDIX  AND 
ITS  DISEASES. 


CHAPTER    I. 
HISTORY. 

FROM  THE   FIRST  RECORDED   CASE   TO   THE   ESTABLISHMENT  OF  LESIONS   OF 
THE  APPENDIX  AS  PRODUCTIVE  OF  WELL-DEFINED  CLINICAL  SYMPTOMS. 

"dependent,  quelques  observations  recuillUs  dans  cesdernien  temps prouvent  que  Vappen- 
dice  vermiforme  peut  devenir,  dans  certains  cas,  le  siige  de  maladies  promptemeni 
mortette." — (Metier,  Jour.  gen.  de  nied.,  1827,  turn.  C,  p.  317.) 

A  knowledge  of  the  morbid  conditions  affecting  the  vermiform  appendix 
belongs  exclusively  to  the  nineteenth  century.  Occasional  descriptions  of 
disease  in  its  structure,  or  of  abnormalities  in  its  size,  shape,  or  position,  are 
found  in  the  autopsy  records  of  an  earlier  date;  but  such  instances  were 
regarded  simply  as  curiosities,  and  excited  no  particular  comment  beyond  a 
passing  conjecture  as  to  a  possible  relationship  between  the  lesion  and  the 
associated  symptoms.  Lesions  of  the  appendix  were  long  looked  upon  as  second- 
ary to  disease  in  other  parts  of  the  intestine,  and  while  this  was  the  case  no 
appreciation  of  their  importance  was  possible. 

It  was  not  until  the  year  1824  that  the  vermiform  appendix  received  recog- 
nition as  an  organ  susceptible  to  disease  arising  primarily  in  its  own  structure; 
and  still  another  sixty  years  elapsed  before  it  was  clearly  and  generally  under- 
stood thai  many  different  abdominal  disorders,  whose  obscure  etiology  was 
slowly  undergoing  differentiation,  might  be  referred  to  a  common  origin  in  an 
inflamed  appendix.  This  great  point  in  the  causation  of  certain  inflammatory 
affections,  so  fatal  in  their  termination,  was  clearly  established  in  1886,  at  a 
period  when  the  whole  domain  of  surgery  was  undergoing  the  remarkable  evo- 
lution immediately  following  the  introduction  of  antisepsis.  The  treatment 
of  appendicitis  by  means  of  celiotomy  thus  assumed  importance  from  the  moment 
the  true  nature  of  the  disease  began  to  be  understood,  and  the  frequent  opening 
of  the  abdominal  cavity  supplied,  in  its  turn,  opportunities  for  the  investigation 
of  the  disease  in  all  its  stages  which  had  heretofore  been  lacking. 

The  literature  of  the  subject,  insignificant  in  its  beginning,  increased  after 

l 


2  BISTORY. 

the  year  1886  with  great  rapidity,  and  lias  now  assumed  such  proportions  thai 
it  is  no  longer  possible  for  a  surgeon  not  devoting  himself  to  its  special  study 
to  keep  abreast  of  it.  In  the  present  historical  review  my  aim  has  been  i<> 
emphasize  the  notable  contributions  which  have  marked  periods  of  progress, 
rather  than  to  offer  an  imposing  array  of  names.  I  present  here,  therefore,  a 
sifted  literature,  from  which  I  trust  my  leaders  will  agree  thai  I  have  selected 
those  names  most  worthy  of  being  retained  in  the  medical  hall  of  fam< — names 
of  men  possessing  discrimination  and  keen  insight;  men  who  have  reasoned 
on  the  problems  presented  at  the  bedside  and  at  the  autopsy  table;  men  who 
have  even,  in  some  instances,  forestalled  the  slow  march  of  history  by  brilliant 
prophecy, 

The  first  r e c o r  d  e d  case  of  d  i s  ease  of  the  appendix 
is  the  classical  one  of  Mesttvier,  reported  in  1759.*  A 
man  of  forty-five  sought  relief  for  a  tumor  in  the  umbilical  region  on  the  right 
side;  fluctuation  could  be  detected,  and  about  a  pint  of  pus  was  evacuated  by 
an  incision;  the  wound  healed  readily,  but  the  patient  died  shortly  afterward. 
The  account  of  the  autopsy  is  that:  "The  cecum  presented  nothing  extraor- 
dinary; it  was  covered  with  gangrenous  patches.  It  was  not  the  same  with 
the  vermiform  appendix;  I  had  scarcely  opened  it  when  we  found  a  large  pin, 
very  rusty,  and  so  corroded  in  certain  places  that  the  least  touch  would  have 
broken  it  ;  a  condition  which  proceeded,  no  doubt,  not  only  from  moisture,  but 
from  the  acrid  nature  of  the  material  enclosed  in  the  vermiform  appendix.  After 
what  I  have  just  said,  it  is  easy  to  understand  (although  the  patient  had  never 
spoken  of  swallowing  a  pin)  that  the  one  under  discussion  had  been  concealed 
for  a  long  time  in  the  vermiform  appendix  of  the  cecum;  and  that  it  was 
undoubtedly  this  which  had  irritated  the  different  coats  of  which  the  organ  is 
composed,  and  had  given  rise  to  all  the  patient's  symptoms,  finally  causing  the 
death  which  ensued,  ''t 

In  the  year  1766,  Joubert  Lamotte,  a  student  of  medicine  at  the  University 
of  Angers,  published  a  paper  entitled  "Ouverturedu  cadavre d'une personne morte 
d'une  tympanite."  This  patient  suffered  for  some  months  before  death  with 
attacks  of  violent  colic,  the  result  apparently  of  an  intestinal  obstruction,  since 
it  is  stated  that  "purgatives  could  not  pass,  and  enemas  returned  unchanged." 
"The  intestines,  "the  writer  goes  on  to  say,  "were  so  inflated  that  the  mesentery 
and  the  mesocolon  ("the  glands  in  which  were  completely  obstructed)  were  as 
tense  as  the  skin  of  a  drum.  The  size  of  the  large  and  small  intestines  was  nearly 
the  same,  and  the  cecum  was  so  large  that  it  exactly  resembled  an  immense 
bladder  filled  with  air.     Its  vermiform  appendix,  which  was  a  good  inch  ['un  bon 

I  debohls,  in  his  excellent  "Review  of  the  History  and  Literature  <>f  Appendicitis,"  cites 
this  case  as  that  of  a  woman  in  the  eighth  month  of  pregnancy;  but  the  reference  has  been 
carefully  verified,  and  the  facts  found  as  noted. 

t  Sec  historical  bibliography  at  the  end  of  the  third   chapter   (page  52)  for  all  references 

Contained  in  tin-  tir-t  three  chapters. 


LAMOTTE.      JADELOT.       PARKINSON.  3 

pouce']  in  length,  was  wider  than  in  its  natural  state.  The  fact  appeared  to 
me  so  extraordinary  that  I  wished  to  ascertain  what  the  organ  could  contain; 

I  touched  it,  ami  I  felt  a  foreign  body,  as  hard  as  if  it  were  petrified 

When  the  cecum  was  reached,  we  found  it  filled  with  whole  cherries.  I  say 
cherries,  and  not  nuts,  although  their  color  was  a  dark  brown.  After  having 
evacuated  some  fecal  matter,  we  drew  forth  the  hard  body  which  I  had  felt 
through  the  coats  of  the  intestine.  It  was  the  size  of  a  large  orange,  and  it 
resembled  a  compact  potato,  that  is  to  say,  one  of  those  which  are  much  less 
elongated  than  they  are  in  general;  its  weight  was  four  ounces,  its  consistency 
that  of  fine,  well-worked  butter,  its  color  internally  nearly  that  of  an 
ordinary  sponge;  it  seemed  to  be  about  as  compact  as  touchwood."'  The 
writer  makes  no  comment  on  the  appearances  he  describes,  and  apparently 
he  formed  no  opinion  in  regard  to  them.  The  case  stands  on  record 
simply  as  the  first  account  in  the  literature  of  fecal  concretions  in  the 
vermiform  appendix. 

In  1790  the  EncydopMie  methodique  was  issued,  the  second  volume 
of  which  contains  an  article  on  "Tumors  and  Tubercles,"  where  an  incidental 
allusion  occurs  to  the  condition  of  the  appendix  in  a  case  of  death  resulting  from 
disease  of  the  lungs.  "  In  the  appendix  of  the  cecum  there  was  a  brittle  stone, 
the  size  of  a  small  nut,  which  when  dried  was  inflammable;  in  the  centre  of  the 
layers  of  which  the  little  stone  was  composed  there  was  a  hair."  It  is  also  re- 
marked that  the  jejunum  and  a  portion  of  the  ileum  were  inflamed  and  blackened 
in  certain  places.  In  this  instance  not  only  is  the  presence  of  a  foreign  body 
noted,  but  the  fact  that  a  hair  formed  its  nucleus. 

J  a  helot's,  the  next  case  on  record,  the  first  in  the  nineteenth  century,  was 
published  in  the  year  1S0S.  I  abstract  from  the  Bibliotheque  medicate  for 
1814  a  short  account:  A  boy  of  thirteen  died,  two  (.lays  after  his  entrance  into 
the  Hopital  des  Enfant*,  of  an  ''adynamic  fever'':  at  the  autopsy  a  great  number 
of  lumbricoid  worms  were  found  in  various  parts  of  the  intestines,  including 
four  in  the  vermiform  appendix. 

Up  to  this  date,  1808,  the  history  of  the  vermiform  appendix,  which  con- 
sisted of  the  four  cases  already  cited,  distributed  over  a  half  century,  belong- 
exclusively  to  France. 

In  the  year  1812  a  case  was  reported  in  England  by  a  London  physician, 
Parkinson.  The  patient,  a  boy  of  five,  died  after  two  days'  illness  charac- 
terized by  vomiting,  great  prostration  of  strength,  and  barely  percept- 
ible pulse.  The  abdomen  was  distended  and  painful  on  pressure.  The  autopsy 
showed  a  general  peritonitis  with  recent  adhesions.  All  the  viscera  were  healthy 
except  the  appendix,  which  was  perforated  by  an  ulcer  the  size  of  a  crow-quill, 
through  which  its  contents  had  escaped  into  the  peritoneal  cavity  and  con- 
tained a  piece  of  hardened  feces.  Our  author  presents  this  case  in  the  purely 
objective  manner  characteristic  of  these  early  reports,  but  it  is  plain  thai  he 
recognized    the    perforati o  n    in    t  h  e    a  p p  e  n  d  i  x     a s     the 


4  HISTORY. 

cause   of    death;    he   is    therefore   out  it  lid    to   the    credit 
of    priority    in    this    r  es  pe  c  t. 

In  1813,  a  year  after  the  appearance  of  Parkinson's  case,  another  paper 
was  published  in  France  by  a  German  named  Wegeler.  A  boy  of  eighteen 
died  with  all  the  symptoms  of  appendicitis,  including  pain  in  the  right  iliac 
fossa  accompanied  by  vomiting,  which  finally  became  fecal;  examination 
showed  an  area  of  inflammation  at  the  juncture  of  the  ileum  with  the 
colon,  while  the  cecum  was  destroyed  by  gangrene,  having  it >  starting- 
point,  the  writer  states,  in  the  vermiform  appendix,  in  which  organ  a  hard 
body  could  lie  felt,  found  on  dissection  to  consisl  of  several  stones  (lapides), 
three  of  them  the  size  of  peas,  and  the  fourth  as  large  as  a  pigeon's  egg.  The 
other  abdominal  organs  were  healthy.  Wegeler  did  not  believe  thai  these 
stones  were  the  original  cause  of  disease,  but  he  considered  it  prob- 
able that  if  the  in  f  1  a  m  m  a  t  0  r  y  c  on  d  i  1  i  0  n  h  a  d  0  r  i  g- 
iiuiti'il  fro  in  o  t  h  e  r  c  a  u  s  e  S,  the  p  r  e  s  e  n  c  e  of  irritating 
substances  in  such  a  situation  might  easily  augment 
an  otherwise  trifling  evil.  He  regarded  the  stones  as  biliary 
calculi,*  which  had  undergone  change  from  the  action  of  the  intestinal  secre- 
tions: and  lie  subjected  them  tn  chemical  analysis,  the  results  of  which  were 
as  follows: 

Lapidis  granum  1  constal  ';e  e 

Materia  pingui  adiposa     0.60  gm. 

Phosphat   calcis  0.30    " 

Materia  animali  0.08    " 

Ponderis  diminutio  erat  0.02     " 

1  on  gm. 

This  paper  is  distinctly  an  advance  on  anything  previously  written,  for  no! 
only  does  the  writer  clearly  recognize  disease  of  the  appendix  as  the  cause  of 
death,  but  he  attempts  to  elucidate  the  part  played  by  the  foreign  bodies,  and 
submits  a  careful  analysis. 

Wegeler's  work  attracted  some  attention  at  the  time  of  its  appearance,  and 
became  the  subject  of  discussion  at  a  medical  meeting  at  Paris  shortly  after 
its  publication;  without  effect,  however,  so  far  as  the  stimulation  of  thought 
is  concerned,  for  nothing  more  of  significance  appeared  for  yet  another  decade. 

In  the  year  1  ^_M  a  Frenchman,  Louyer-Villermay,  published  an  article 
which  at  once  established  a  definite  place  lor  lesions  of  the  appendix  in  the 
category  of  recognized  diseases.     The  title  of  this  paper,  "Observations  jiour 

ira  I'histoin  dt  inflammations  </<  Vappt  ndice  cecale,  "  is  in  itself  suggestive  of 
a  marked  advance  in  knowledge,  since  w  e  here  find  the  firsl   recog- 

*  This  i»  i!h-  lir-i  of  .-i  series  of  statements  that  biliary  calculi  have  been  found  in  the  appi  n- 
<lix,  extending  down  to  our  day.  no  one  of  which  has  yet  been  satisfactorily  proved.  (See  pp. 
2  18  and  363 


LOUYER-YILLERMAY.  5 

nit  ion  of  the  fact  that  the  appendix  as  a  diseased 
organ  c  o  n  I  d  h  a  v  e  an  individual  hist  n  r  y.  He  gives  an 
account  of  two  cases,  which  I  quote  somewhat  in  detail,  as  they  arc  the  first 
clinical  histories  recorded  at  length. 

Case  1. — A  man  of  thirty-five  was  suddenly  attacked  with  violent  pain  in 
the  right  side  of  the  abdomen,  followed  by  vomiting;  the  abdomen  was  extremely 
sensitive  to  pressure  in  the  right  iliac  fossa.  The  right  testicle  was  strongly 
retracted.  There  had  been  no  premonitory  symptoms, except  acoldness  of  the 
dorsum  of  the  right  foot,  present  for  several  days  before  the  on-set  of  the  attack. 
lit  is  curious  that  this  particular  symptom  made  a  decided  impression  at  the 
time,  and  is  referred  to  by  subsequent  writers,  who  seem  to  have  sought  it  con- 
stantly as  a  prodromic  symptom  of  appendicitis.)  Remedies,  such  as  poultices 
and  leeches  to  the  right  iliac  fossa,  were  without  effect,  and  the  patient  grew 
gradually  worse  until  the  fourth  day.  when  he  died  tranquilly.  At  the  autopsy, 
twenty-four  hours  later,  the  testicle  was  found  near  the  abdominal  ring,  but 
sound.  In  the  right  iliac  fossa  there  was  a  collection  of  about  five  ounces  of 
a  dark  serous  liquid  with  a  gangrenous  odor,  in  the  midst  of  which  the 
vermiform  appendix  was  floating.  This  organ  was  about  one-third  longer  and 
wider  than  usual,  perfectly  black,  gangrenous,  and  putrefied.  The  evidences 
of  gangrenous  inflammation  decreased  from  the  vicinity  of  the  appendix,  dis- 
appearing entirely  in  the  cecum,  which  was  healthy.  The  folds  of  peritoneum 
around  this  part  of  the  intestine,  dotted  here  and  there  with  small  spots  of 
gangrene,  were  adherent  to  the  iliac  fossa.  The  cellular  tissue  surrounding 
the  right  kidney  was  full  of  sero-purulent  liquid,  but  the  kidney  itself  was 
normal.  The  mucosa  of  the  stomach  was  red  and  thickened,  but  that  of  the 
intestines  was  normal,  and  all  the  other  organs  of  the  body  were  healthy. 

Case  2. — The  patient  was  a  man  of  thirty-seven,  with  a  right  inguinal  hernia 
supported  by  a  truss.  One  evening  he  was  taken  ill  with  nausea  and  severe 
colic,  with  a  sense  of  oppression  in  the  umbilical  region,  which  continued  without 
intermission  until  morning,  when  there  was  a  short  period  of  relief  during  which 
he  was  seen  by  a  physician.  The  umbilical  region  was  then  slightly  sensitive 
to  touch  and  both  hypochondriac  regions  were  swollen.  The  pain  soon  re- 
turned, and  after  a  few  hours  became  localized  in  the  right  iliac  fossa,  being 
accompanied  by  vomiting,  dysuria,  and  abdominal  distention.  Death  occurred 
during  an  interval  of  relief  following  syncope,  about  thirty-six  hours  after  the 
onset  of  the  attack.  The  autopsy,  held  twenty-four  hours  after  death,  showed 
a  pyramidal  body  in  the  right  iliac  fossa,  which  proved  to  be  the  appendix. 
It  was  about  three  inches  long,  and  about  one  inch  in  diameter  at  its  1- 
its  color  was  a  dark  violet,  and  it  was  turned  toward  the  inguinal  ring,  which 
was  much  dilated.  Its  mucous  membrane  was  thickened  and  of  a  silvery 
whiteness  near  the  cecum,  but  black  and  discolored  in  the  rest  of  its 
extent.  The  cecum  was  healthy  up  to  the  point  of  attachment  of  the 
appendix.     The   intestines   were   distended   by  gas.    though   otherwise  normal, 


()  HISTORY. 

Init  the  mucous  membrane  of  the  stomach  showed  signs  of  inflammation. 
The  other  organs  were  healthy. 

The  writer  observes:  "These  two  cases  appear  to  us  to  belong  to  the 
same  disease,  for  the  incidental  occurrence  of  an  inguinal  hernia  in  one  does 
not  make  any  important  difference  in  the  nature  of  the  affection,  nor  oven 
in  its  course,  since  it  was  completely  reduced.  It  is.  of  course,  possible  that 
the  appendix  had  originally  formed  pari  of  the  hernia,  and  had  thus  acquired 
its  unusual  size,  but  only  possible,  since  examination  of  the  ring  and  of  the 
scrotum  did  not  show  any  apparent  trace  of  such  a  condition.  Therefore, 
these  two  cases  seem  to  me  identical,  although  offering  some  external  differ- 
ences. In  both,  we  see  a  man  in  the  prime  of  life,  with 
a  g  o  o  d  C  mist  it  lit  io  n,  S  ud  d  enl  y  attacked  in  the  midst 
o  f  ]i  e  r  f  e  c  t  h  e  a  1th  1>  y  a  n  i  n  f  1  a  m  mat  i  o  n  o  f  t  h  e  m  o  s  t 
a  c  u  t  e  c  h  a  r  a  c  t  e  r.  w  i  t  h  a  ra  p  i  d  I  y  fatal  I  e  r  m  inat  in  n. 
In  both,  death  was  preceded  by  a  deceitful  calm  suggesting  amelioration,  and 
when  it  occurred  was  free  from  pain."  It  may  lie  noted  in  this  connection  that 
the  occurrence  of  death  "sans  agonie,"  or,  as  some  of  the  older  writers  express 
it.  "  phiriiln  morte,"  is  frequently  alluded  to  in  early  descriptions  of  appendicitis. 
Villermay  goes  on  to  observe  that  "Treatment  was  equally  useless  iii  both  cases. 
The  autopsies  presented  some  differences  in  detail,  but  the  fundamental  lesion 
was  the  same  in  both;  the  same  organ,  the  appendix,  being  affected  in  the 
same  manner,  and  death  ensuing  with  equal  rapidity.  In  both  cases  the  gan- 
grenOUS  process  involved  the  whole  of  the  appendix,  but  extended  from  it  only 
in  an  accessory  manner,  and  within  very  narrow  limits;  the  entire  peritoneum, 
the  bulk  of  the  intestines,  the  interior  of  the  cecum,  and  all  the  other  viscera 
being  free  from  it.  The  inflammation  of  the  mucous  membrane  of  the  stomach 
probably  proceeded  from  sympathetic  irritation  produced  by  vomiting."  In 
conclusion,  he  asks:  "But  how  could  the  inflammation  of  an  organ  of  such 
small  size,  and  more  especially  of  such  limited  importance,  occasion  death  so 
rapidly,  and  without  resulting  peritonitis?  We  are  equally  in  the  dark  as  to 
whether  disease  of  this  organ  will  be  always  followed  by  results  as  speedy  and 
as  disastrous." 

A  month  after  the  appearance  of  Louyer-Villermay's  article,  a  paper 
was  published  in  England  by  Blackadder.  This  communication  is  almost 
entirely  occupied  with  the  discussion  of  a  single  case,  presenting  unusual  features. 
A  man.  forty  years  of  age.  fell  suddenly  to  the  ground  in  a  state  of  collapse, 
without  premonitory  symptoms  of  any  kind.  He  complained  of  excruciating 
pain  in  the  abdomen,  which  was  exquisitely  sensitive  to  touch,  and  is  de- 
scribed as  "greatly  and  permanently  retracted."  while  the  respiration  was 
purely  thoracic.  Death  occurred  in  three  and  a  half  hours  from  the  onset  of 
the  attack.  A  postmortem  examination  showed  the  heart  much  enlarged,  with 
a  clot  extending  nearly  to  the  arch  of  the  aorta.  The  abdominal  viscera  were 
healthy,  except   the  vermiform  appendix,  which  was  remarkably  increased  in 


BLACKADUER.       MELTER.  7 

length  anil  thickness,  resembling  a  firm  cord  to  the  touch;  its  cavity  was  filled 
by  a  large  lumbricoid  worm,  with  its  tail  projecting  into  the  cecum.  No  other 
worms  were  found  in  the  intestine,  and  there  was  no  inflammation.  Blackadder 
considered  that  the  irritation  produced  by  the  worm  caused,  either  directly  or 
reflexly,  a  spasmodic  contraction  of  the  abdominal  muscles,  impelling  the 
action  of  the  already  diseased  heart.  He  mentions  two  other  cases  in  which 
he  had  found  lumbricoids  or  fecal  concretions  in  the  appendix  at  autopsies, 
death  having  occurred  from  causes  altogether  distinct  from  that  organ. 

In  1827  another  Frenchman,  Melier,  published  an  article  so  full  of  thought 
and  insight  that  it  might  well  have  marked  an  historical  epoch  in  the  subject 
had  the  author  possessed  the  courage  of  his  convictions,  and  had  he  been  able 
to  combat  Dupuytren,  the  greatest  surgical  authority  of  his  time. 

Melier  begins  by  noting  that  pathological  anatomy  had  taught  almost 
nothing  in  regard  to  disease  of  the  appendix.  Some  recent  observations,  how- 
ever, he  says,  show  that  disease  of  the  organ  may  assume  a  role  of  the  highest 
importance,  for  under  certain  conditions  it  can  become  the  seat  of  a  rapidly 
fatal  disease.  He  then  cites  Louyer-Villermay's  cases,  and  adds  another  from 
his  own  experience,  in  which  a  patient,  when  apparently  on  the  road  to  recovery, 
after  a  self-administered  enema  had  a  sudden  return  of  agonizing  pain  in 
the  lower  abdomen,  followed  by  an  acute  peritonitis,  and  died  eighteen  hours 
after  the  onset  of  the  second  attack.  At  the  autopsy  the  vermiform  appendix 
was  found  gangrenous  and  perforated  in  several  places.  Melier's  analysis  of 
the  situation  is  this:  "In  my  opinion,  the  fecal  matter  accumulated  in  the 
appendix,  which  then  dilated  little  by  little,  becoming  first  inflamed,  then 
gangrenous,  and  finally  perforated.  The  earliest  symptoms,  appearing  in  the 
form  of  colic,  are  probably  accounted  for  by  the  inflammation  and  distention 
of  the  appendix;  its  rupture  occasioned  the  effusion,  which  was  responsible,  in 
turn,  for  the  peritonitis.  The  perforation  was  determined,  or  at  any  rate 
hastened,  by  the  patient's  exertion  in  taking  an  enema,  since  it  was  at  this 
moment  that  the  intense  pain  began,  and  immediately  afterward  that  peri- 
tonitis set  in."  He  then  cites  two  other  cases,  of  lesser  interest,  in  regard  to 
which  his  own  remarks  are  noteworthy.  "This  disease,"  he  says,  "is 
considered  extremely  rare;  obsei  v  e,  h  o  w  e  v  e  r,  that 
the  five  cases  w  h  i  c  li  f  0  r  m  the  basis  of  this  p  a  p  e  r  h  a  v  e 
been  collected  in  a  short  space  of  t  i  m  e,  and  that  t  w  o 
a  m  o  n  g  the  m  w  ere  r  e  p  o  r  t  e  d  by  the  s  a  m  e  p  h  y  s  i  c  i  a  a  ; 
these  facts  entitle  us  to  believe  that  if  such  affec- 
tions h  a  \-  o  nut  li  e  e  n  in  o  r  e  f  requently  observed,  it  is 
because  the  appendix  has  not  received  s  u f  f  i  c i  e  n  t 
attention,  and  because  lesions  situated  in  it  have 
been  overlooked  at  autopsies.  In  regard  to  diagnosis,  I  will 
say,  further,  that  when  my  friend  Monsieur  Sevestre  was  called  to  the  second 
of  the  cases,  which  he  reported  to  me,  he  w  a  s    a  b  1  e    to    state    p  o  s  i- 


8  HISTORY. 

t  i  v  c  1  y  that  t  li  c  a  p  p  e  n  d  i  x  w  a  s  ;i  I  f  e  c  t  e  d,  so  much  did  the 
symptoms  resemble  those  in  the  first  case,  which  had  struck  him  forcibly  at 
the  time  as  characteristic.  " 

Melier  then  goes  a  step  farther,  and  applies  the  knowledge  gained  from 
these  acute  cases  to  chronic  forms  of  the  same  disease.  A  patient  had  a  tumor 
in  the  right  iliac  I'nssa,  which  yielded  to  treatment,  hut  returned  in  three  years. 
Dupuytren  saw  the  case  in  consultation,  and,  as  fluctuation  could  he  detected, 
the  swelling  was  incised,  evacuating  a  considerable  quantity  of  pus.  The  wound 
remained  open,  continuing  to  discharge,  and  three  new  abscesses  appeared 
a!  a  little  distance  from  the  first,  all  of  which  opened  spontaneously.  This 
condition  lasted  more  than  a  year,  when  the  patient  took  a  violent  cold,  fol- 
lowed by  acute  general  peritonitis  and  death.  The  autopsy  showed  an  immense 
abscess  at  the  seat  of  the  tumor,  communicating  with  the  outside  by  four  open- 
ings. To  this  abscess  adhered  a  part  of  the  cecum,  together  with  the  vermiform 
appendix,  the  latter  being  closely  united  to  the  abscess  walls  by  dense  con- 
nective tissue,  and  opening  directly  into  the  abscess  cavity.  "In  comparing 
this  case."  says  Melier,  "with  the  preceding  ones.  I  am  constrained  to  believe 
that  here  also  the  appendix  cseci  was  the  original  source  of  evil;  that  there  had 

1 n  a  collection  of  fecal  matter  in  its  cavity,  perhaps  even  a  stercoral  calculus, 

and  that  the  appendix,  acutely  inflamed,  had  become  adherent  to  the  peri- 
toneum, the  adjacent  cellular  tissue  becoming  engorged,  and  an  abscess  forming 
in  consequence  of  the  perforation  of  the  appendix."  Could  there  he  a  clearer 
recognition  of  the  causal  nexus  existing  between  disease  in  the  appendix  and 
chronic  suppurative  affections  in  the  right  iliac  fossa?  To  Melier  undoubtedly 
belongs  the  distinction  of  first  appreciating  this  causal  relationship.  lie  had 
not,  however,  unfortunately  for  himself,  sufficient  confidence  in  his  own  judg- 
ment to  maintain  his  theory  unreservedly,  for  he  proceeds  somewhat  timidly: 
"  It  is  possible  that  the  tumor  was  first  formed,  and  the  appendix  secondarily 
affected;  indeed,  it  favors  this  view  that  pus  was  never  present  in  the  stools. 
nor  fecal  matter  in  the  discharge  from  the  wound."  It  is  also  interesting  to 
find  that  he  was  sufficiently  in  advance  of  his  generation  to  suggest  surgical 
treatment  for  the  condition  he  is  discussing.  His  prophetic  words  on  this 
point  are  stated  in  a  foot-note:  "If  it  were  possible,  indeed,  to  establish  the 
diagnosis  of  these  affections  in  a  certain  and  positive  manner,  and  to  show  that 
they  are  always  entirely  circumscribed,  the  possibility  o  f  a  n  o  p  e  r  a- 
t  i  o  n  might  be  conceived:  so  m  e  d  a  y,  p  e  r  h  a  p  s,  this 
result    will    be   reached." 

To  Melier,  then,  belongs  the  credit  of  distinguishing  inflammation  of  the 
appendix  from  inflammatory  conditions  affecting  other  portions  of  the  intestine 
with  greater  acuteness  than  any  of  his  predecessors.  He  first  formulated 
correct  conclusions  as  to  t  h  e  existence  o  f  s  u  c  h  i  n  f  1  a  in  in  a  t  i  o  n 
in  a  chronic  form:  ami  he  first  recognized  t  h  e  c  a  u  s  a  1 
relation    bet  w  e  e  n   t  h  i  s  c  h  r  o  n  i  C   a  f  f  e  c  t  ion    of    the    appe  n- 


MELIEE.  9 

(1  i  x  and  suppurative  tumors  of  the  right  iliac  fossa. 
Finally,  he  first  suggested  t  li  e  possibility  of  relief 
by  means  of  operative  measures.  The  possibility  of  primary 
disease  in  the  appendix  once  established,  lesions  of  the  organ  became  entitled 
to  a  definite  place  in  the  category  of  recognized  diseases,  and  therefore  with 
the  appearance  of  Melier's  article  the  first  stage  in  the  evolution  of  knowledge 
concerning  the  vermiform  appendix  may  be  considered  to  end. 


CHAPTEE  II. 
HISTORY. 

FROM    THE    DISTINCT    RECOGNITION    OF    LESIONS    IN    THE    APPENDIX   TO   THE 
KNOWLEDGE  OF  APPENDICITIS  AS  A  SURGICAL  AFFECTION. 

1827-1886. 

"It  is  the  duty  of  every  physician  to  be  mindful  that,  for  all  practical  purposes,  peri- 
typhlitis, perityphilitic  tumor,  and  perityphlitic  abscess  mean  inflammation  of  the 
vermiform  appendix." — (Reginald  Fit/.,  New  York  Med.  Jour.,  L886,  vol.  47, 
p.  508.  ) 

We  should  naturally  suppose  thai  the  issue  in  rapid  succession  of  two  papers 

so  full  of  interest   as  those  of  l.ouyer-Yillerinav  and  of  .Melier  would   have  been 

followed  by  other  immediate  advances  in  our  knowledge  of  disease  of  the  appen- 
dix. Such  was  not  the  case,  however,  and,  notwithstanding  the  excellence  of 
this  beginning,  the  further  development  of  the  subject  was  slow  and  uncertain, 
owing  to  greal  misdirection  of  effort.  Abscess  in  the  righl  iliac  fossa  at  this 
time  began  to  receive  considerable  attention,  especially  in  France,  where  .Melier, 
as  we  have  jus!  seen,  clearly  recognized  its  relation  to  inflammation  of  the 
appendix.  His  views  failed  of  acceptance,  however;  mainly  because  the  most 
eminent  surgeon  of  the  time,  Dupuytren,  took  a  contrary  position.  The  history 
of  our  subject,  indeed,  affords  at  this  point  a  striking  example  of  the  difficulties 
encountered  by  originality  of  idea  when  opposed  to  the  weighl  of  established 
authority.  Dupuytren  stated  emphatically  that  he  believed  the  reason  such 
abscesses  were  met  with  on  the  righl  side  rather  than  the  left  was  to  be  found 
in  the  natural  anil  pathological  relations  of  the  intestine  in  that   region.     The 

fact  that  tin'  intestinal  canal  ceases  at  this  point  to  be  freely  movable,  thai  f 1 

material  here  begins  to  assume  an  eMcreniontal  character,  and  to  be  forced 
onward  in  opposition  to  the  laws  of  gravity,  together  with  the  occurrence  of 
~ia-is,  favored  by  the  smallness  of  the  opening  between  the  small  and  the  large 
intestine,  were,  in  his  opinion,  sufficient  reason  for  the  appearance  of  these 
tumors  in  the  righl  iliac  fossa.  This  opinion  was  formally  expressed  in  the 
/.irons  chirurgicales  which  appeared  in  1833,  but  it  had.  no  doubt,  been  long 
before  impressed  orally  on  Dupuytren's  students.  Two  of  the  latter,  indeed, 
Husson  and  Dance,  published  a  paper  in  1Sl>7.  in  which  they  developed  Dupuy- 
tren's views  with  much  completeness,  and  (as  they  are  careful  to  sayj  with 
Dupuytren's  approval. 

MexiEiu;,  in  1828,  published  an  article  in  which  he  also  insisted  on  a  cecal 
10 


DUPUYTRKX.       MENIERE.  11 

origin  for  what  ho  terms  "tumeurs  phlegmoneuses,"  advancing  his  theory  that 

their  exciting  cause  was  an  impaction  of  feces.  In  his  opinion  there  was 
no  connection  between  these  tumors  and  the  vermiform  appendix,  and  in  sup- 
port of  this  conviction  lie  cites  the  same  case  which  Melier  had  previously  used 
to  prove  the  relation  between  the  two  in  cases  of  chronic  suppuration  of  (he 
right  iliac  fossa.  It  will  be  remembered  that  this  case  was  one  in  which  a 
fluctuating  tumor  existed  in  the  fossa,  and  after  some  time  the  pus  burrowed 
under  the  psoas  muscle  until  it  pointed  externally.  An  incision  (made  by 
Dupuytren)  brought  no  relief,  and  the  patient  finally  died  of  exhaustion.  At 
the  autopsy  the  appendix  was  found  full  of  fecal  concretions,  adherent  to  the 
peritoneum,  and  opening  into  the  intestine.  Melier,  as  we  have  said,  believed 
in  the  causal  relation  between  the  diseased  appendix  and  the  tumor,  but,  un- 
fortunately for  himself,  he  failed  to  insist  upon  it,  as  he  considered  the  absence 
of  pus  in  the  stools,  and  of  feces  in  the  discharge  from  the  external  wound, 
inconsistent  with  his  theory,  and  honestly  admitted  the  fact.  His  frankness  on 
this  point  gave  Meniere  the  opportunity  to  reject  his  opinion,  with  the  remark 
that  the  originator  himself  did  not  really  support  it.  Dupuytren  also  brings 
forward  this  same  case  in  the  Lemons  chirurgicales,  where  he  expresses  himself  as 
in  agreement  with  Meniere.  More  courteous  than  the  latter,  however,  he  adds 
that  no  doubt  there  is  such  a  thing  as  disease  of  the  vermiform  appendix,  and 
his  former  pupil,  Monsieur  Melier,  has  written  an  admirable  paper  upon  the 
subject;  a  remark  evidently  prompted,  however,  by  perfunctory  professional 
courtesy,  for  he  declares  himself  emphatically  opposed  to  the  theory  of  any 
causal  relation  existing  between  right-sided  iliac  tumors  and  inflammation 
of  the  vermiform  appendix.  There  can  be  no  doubt  that  Dupuytren  stood 
upon  the  brink  of  a  great  discovery,  and  that  he  entirely  failed  to  appreciate 
the  fact;  worse  still,  his  lack  of  perception  absolutely  hindered  the  progress 
of  investigation  by  depreciating  the  influence  of  the  man  whose  insight  had 
discovered  the  line  which  further  research  ought  to  pursue.  It  is  a  pleasure, 
therefore,  to  be  able  after  the  lapse  of  more  than  three-quarters  of  a  century, 
in  rendering  honor  to  whom  honor  is  due,  to  accord  Melier  his  rightful  position, 
foremost  among  pioneers  in  the  study  of  diseases  in  the  appendix. 

The  theory  that  suppurative  tumors  in  the  right  iliac  fossa  arose  from 
cecal  disturbances  of  one  kind  or  another  thus  became  firmly  established,  and 
remained  dominant  for  over  half  a  century,  until,  in  fact,  it  was  gradually 
thrust  aside,  or  rather  supplanted,  for  it  was  never  formally  abandoned.  Al- 
though Dupuytren  and  his  followers  failed  to  understand  the  real  significance 
of  disease  in  the  appendix,  they  did  the  cause  good  service  by  stimulating  inves- 
tigation, and  the  reports  of  primary  lesions  of  the  appendix  from  now  on  increased 
year  by  year,  until  the  frequency  rather  than  the  rarity  of  such  disease  became 
generally  admitted,  and  correct  opinions  in  regard  to  its  natural  history  began 
gradually  to  take  form. 

Up  to  this  time,  that  is  to  say,  the  end  of  the  third  decade  of  the  nineteenth 


12  H I  STORY . 

century,  all  interest  in  diseases  of  the  appendix  had  been  confined  to  England 
ami  tu  France.  Imt  we  have  now  readied  a  print  when  Germany,  hitherto 
silent,  began  to  contribute  her  quota  of  observations. 

Goldbeck,  in  the  year  1830,  issued  an  inaugural  dissertation  at  Worms, 
entitled  "Ueber  eigenthumlictu  Gi  chwulste  in  der  rechten  Hiiftbeingegend," 
which  stimulated  interest  in  Germany  just  at  the  moment  when  it  began  to 
decline  in  France,  and  for  the  next  twenty-five  years  all  contributions  to  the 
subject  of  interest  or  importance,  with  a  few  notable  exceptions,  were  German. 
Those  Teutonic  discussions  form  a  distincl  episode  in  the  history  of  the  vermi- 
form appendix,  which  has  not  as  yet  been  duly  estimated.  1  will,  therefore, 
present  this  historical  phase  of  our  subject  at  this  point,  deferring  for  the  moment, 
for  the  sake  of  completeness,  the  consideration  of  the  few  important  papers 
appearing  in  other  countries  during  this  quarter  of  a  century. 

The  subject  of  Goldbeck's  thesis,  inflammatory  tumors  in  the  right  iliac 
fossa,  was  adopted  at  the  suggestion  of  his  master,  Pi  <  in  i.r,  who  had  given  close 
attention  to  these  tumors,  the  results  of  which,  when  finally  collected,  appeared 
in  the  Heidelberger  Jdinische  Annalen,  f<>r  1832.  Both  Puchelt  and  his  scholar 
held  that  these  tumors  were  the  result  of  collections  of  pus  in  the  loose  con- 
nective tissue  surrounding  the  cecum:  to  this  condition,  therefore,  which  they 
believed  to  be  of  cecal  origin,  they  gave  the  name  "perityphlitis.'' 
This  convenient  and.  may  I  say.  euphonious  term  met  with  immediate  general 
acceptance,  and  even  yet  continues  in  use  in  Germany  and  England.  Differ- 
ences of  opinion  are  often  found  among  later  writers  as  to  the  real  origin  of 
this  term;  did  it  originate  with  Goldbeck  or  with  his  master?  To  settle  this 
question  it  seems  worth  while  to  quote  Puchelt 's  own  words.  "Ich  selbst 
h  a  he,"  he  says,  "cine  n  f  r  ii  h  e  r  e  n  S  c  h  ii  1  e  r  v  o  n  m  i  r,  II  e  r  r  n 
D  r.  <!  o  1  d  h  e  c  k,  v  e  r  a  D  1  as  s  t  die-  e  o  <  i  e  g  e  n  s  t  a  n  d  z  u  li  e  a  r- 
li  e  i  t  e  n,  u  n  d  e  s  e  r  s  c  h  i  e  n  d  i  e  S  c  h  r  i  f  t  d  <■  ss  elb  e  n  a  1  s 
In  augur  al  abh  and  1  ung  zu  Giessen,  unter  dem  Titel: 
'Ueber  eigenthumliche  entziindliche  G  e  s  c  h  w  ii  1  s  t  e 
in  der  rechten  Hiiftbeingegend.'  In  dieser  Schrift 
w  i  r  d  1  >  e  i-  e  i  t  s  der  Name  Perityphlitis  f  ii  r  <  1  i  e  s  e  K  r  a  n  k- 
h  e  i  t  v o r  ,Lr  eschlage  n,  d  e  n  w  i  r  1>  e  i  d  e  gemeinschaftlic  h 
•_r  e  h  i  1  il  e  t  ha  1 1  e  n:  ich  h  of  f  e  d  a  s  s  e  r  e  1>  e  n  s  o  s  p  r  a  c  h- 
r  i  ch  t  ig  i  s  t.  als  er  d  e  r  S  a  c  h  e  entspric  h  t. '"  Surgery,  however, 
has  no  reason  to  be  grateful  for  this  denomination,  either  to  Goldbeck  or  to 
his  master,  a-  the  name  perityphlitis  is  altogether  misleading,  diverting 
attention  from  the  real  source  of  evil,  the  appendix,  and  clogging  the  wheels 
of  progress  for  more  than  half  a  century  by  leading  inquirers  on  the  subject 
astray. 

The  excellent  clinical  picture  of  inflammation  of  the  appendix  drawn  by 
Puchelt  and  Goldbeck  would  answer  well  for  a  description  of  the  disease  in 
a  text-book  of  to-day,  lmt  so  far  were  they  from  understanding  the  real  signifi- 


GOLDBECK.      MERLING.  13 

cance  of  the  symptoms  depicted,  that  Goldbeck  says  frankly  lie  is  at  loss  for 
an  explanation  of  them,  and  that  the  reason  these  tumors  do  not  make  their 
appearance  on  the  left  side  is  one  for  consideration.  lie  suggests  that  the 
position  of  the  cecum  favors  the  accumulation  of  pus  on  the  right  side,  when 
on  the  left  side  the  resistance  offered  by  the  surrounding  peritoneum  and  the 
mesocolon  forces  the  pus  to  burrow  under  the  ilium  and  point  toward  the  exterior 
in  that  direction,  or  else  to  destroy  the  connective  tissue  in  the  region  of  the 
rectum  and  form  a  rectal  fistula. 

The  immediate  result  of  Goldbeck's  essay  was  the  stimulation  of  others 
on  the  same  subject.  I  find  not  less  than  twenty-four  theses  treating  of  diseases 
in  the  right  iliac  fossa  making  their  appearance  between  the  years  1830  and 
1860,  of  which  number  nineteen  issued  from  German  universities.  It  is  note- 
worthy that  nearly  all  the  early  work  contributed  by  Germany  to  the  study 
of  the  appendix  is  embodied  in  dissertations,  whereas  in  France  and  in  Great 
Britain  it  found  expression  almost  entirely  in  periodicals.  In  these  German 
theses  we  find  iliac  tumors  considered  as  primary  disorders  per  se,  and  it  is  only 
when  we  interpret  them  in  the  light  of  knowledge  lately  acquired  that  we 
are  able  to  read  between  the  lines  and  discover  the  information  contained  in 
them  as  to  disease  of  the  appendix,  the  authors  themselves  being  ignorant  of 
the  true  significance  of  their  work. 

Merling,  in  1n27.  published  a  thesis  on  the  pathological  anatomy  of  the 
appendix,  in  which  the  natural  history  of  the  diseased  conditions  affecting 
that  organ  is  for  the  first  time  independently  discussed.  A  considerable  part 
of  the  dissertation  is  devoted  to  anatomical  variations,  displacements,  and 
adhesions,  but  the  process  of  inflammation  is  also  clearly  described. 

The  most  striking  characteristic  of  these  German  theses,  in  the  light  of  our 
present  knowledge,  is  the  beautiful  accuracy  of  their  symptomatology,  a  quality 
which  seems  to  lie  less  appreciated  to-day.  The  occurrence  of  diarrhea  in  the 
early  stages  of  appendicitis  is  universally  noted,  together  with  the  wandering 
character  of  the  pains  al  first,  in  regard  to  which  Puchelt  says:  "Oritur  ventris 
dolor  crucian.-,  pungens,  vagus,  in  regione  epigaslrica,  imprimis  ventricvli  ct 
alibi  ....  Ule  rem  dolor  nychtemera  nondum  finito  migrai  ad  regionem 
iliacam  dextram,  eique  inhceret  firmiter."  More  than  one  writer  takes  occasion 
to  remark  that  the  pain  in  inflammation  of  the  appendix  must  vary  with  varia- 
tions in  the  anatomical  position  of  the  organ,  and  one  of  them  in  particular, 
Gexzmer,  published  an  able  dissertation  in  lsl_\  giving  an  admirable  exposition 
of  this  point.  Schmidt  also,  writing  in  1S47  upon  the  differential  diagnosis  of 
inflammation  of  the  appendix,  almost  describes  our  McBurney's  point,  for  he 
declares  that  a  diagnostic  sign  in  the  disease  is  the  increase  in  the  severity  "l 
the  pain  caused  by  pressure  in  the  region  of  the  cecum,  over  an  area  scarcely 
the  size  of  the  thumb,  or  even  so  small  that  it  can  be  covered  by  the  tip  of  the 
finger.  "Pressu  dolor  augetur,  ita  ut  cegri  exclamationes  rix  retincre  possint, 
in  parvido  tanlmn  regionem  ileo-coecalis  loco.  <iui  vix  pollicis  drcuitu  est,  plerumque 


14  HISTORY. 

vera  tarn  parvus  est  ui  extremo  digito  facile  legos;  quod  symptoma  sane  rum  mi huho 
ad  diagnoscendum  hunc  momento  mihi  videlur."  It  is  impossible  nol  to  fee] 
a  momentary  surprise  that  knowledge  concerning  disease  of  the  appendix 
should  have  advanced  so  slowly  in  the  presence  of  such  nice  discrimination. 
A  second  thought  reminds  vis.  however,  that  although  these  early  German 
writers  described  symptoms  so  accurately,  they  never  ascribed  them  to  their 
real  source.  Puchelt  himself  wholly  tailed  even  to  suspect  the  causal  nexus 
between  the  appendix  and  perityphlitis,  and  although  occasional  writers  like 
Genzmer  and  Schmidt  did  actually  recognize  the  existence  of  an  acute  appen- 
dicitis, it  was  considered  as  a  greal  rarity.  No  one  appeal's  to  have  entertained 
the  suspicion  that  inflammation  of  the  appendix  was  the  real  cause  of  the  iliac 
tumors  with  which  all  surgeons  of  that  time  were  constantly  occupied,  the 
cecum  itself  and  the  pericecal  tissue  being  regarded  as  the  fons  et  <>rni<>  malorum. 

Albers,  in  1838,  published  a  paper  on  the  cecum,  which,  contributing  nothing 
new,  yet  calls  I'm-  mention  because  of  the  introduction  of  another  misleading 
term,  namely,  that  of  "typhlitis"  for  inflammation  of  the  cecum,  anil 
because  he  points  out  that  Puchelt  had  not  discriminated  between  this  condi- 
tion and  inflammation  around  the  cecum,  to  which  Albers  restricts  the  name 
"perityphlitis." 

Leaving  the  subjecl  of  German  literature,  and  returning  to  that  of  other 
lands.  I  find  four  systematic  British  contributions  to  the  history  of  the  appendix 
during  the  fourth  decade  of  the  century — one  by  Copland,  one  by  Hodgkin, 
one  by  Bkicht  and  Addison,  and  one  by  Burne.  Copland's  contribution 
is  in  the  form  of  an  article  on  the  "Cecum"  in  his  own  Dictionary  of  Practical 
Medicine,  the  first  edition  of  which  appeared  about  1832.  To  Copland  belongs 
the  credit  of  first  discriminating  between  inflammation  of  the  cecum,  inflam- 
mation of  the  appendix,  and  inflammation  of  the  pericecal  tissue,  lie  recog- 
nized primary  disease  of  the  appendix,  but.  in  common  with  other  writers  of 
the  time,  believed  that  such  disease  began,  as  a  rule,  in  the  cecum  and  manifested 
iis  extension  into  the  appendix  by  symptoms  indicating  a  high  degree  of  inflam- 
mation; indeed,  lie  claims  that  inflammation  of  the  appendix  can  always  be 
distinguished  by  the  severity  of  the  symptoms  as  compared  with  those  attending 
inflammation  of  the  cecum  alone.  All  writers  of  the  period  seem  to  have 
attached  great  importance  to  this  supposed  association  between  disease  of  the 
appendix  and  a  high  degree  of  pain  and  constitutional  disturbance.  ('  o  p  1  a  n  d 
is.  T  belie  v  e,  the  first  p  e  r  s  o  n  to  i  n  elude  b  1  o  w  s  a  n  d 
violent  exertion  among  the  e  x  c  i  t  i  n  g  c  aus  es  of  d  i  s- 
•  a  s  e  i  n  the  a  p  p  e  n  d  i  x.  lie  further  considers  in  some  detail  the  sup- 
posed relationship  between  dysentery  and  disease  of  the  appendix,  which  he 
noticed  during  a  long  residence  in  India,  without,  however,  citing  a  single 
case  in  which  such  an  association  was  demonstrated,  nor  have  I  met  any 
instance  among  the  older  writers,  who  persistently  tabulate  dysentery  in  the 
etiology  of  appendicitis.     It  seems,  therefore,  that  the  idea  of  an  interdependence 


HODGKIX.       BRIGHT    AND    ADDISON.  15 

between  dysentery  and  disease  of  the  appendix  and  cecum  originated  rather 
in  a  passing  notion,  which,  once  born,  was  nursed  as  the  legitimate  offspring 
of  fact  by  one  writer  after  another  for  a  series  of  years. 

Thomas  Hodgkix.  true  follower  of  the  great  John  Hunter,  in  his  "Lectures 
on  the  Morbid  Anatomy  of  tfie  Serous  and  Mucous  Membranes,"  published 
in  ISoo,  says  with  remarkable  clearness  but  vexatious  brevity  that  "the  partial 
inflammation  of  the  peritoneum,  in  the  iliac  fossa,  is  sometimes  set  up  by  dis- 
ease in  the  appendix  ceci,"  which  may  be  limited,  or  may  go  on  to  ulceration 
caused  by  the  lodgment  of  fecal  concretions  in  its  cavity.  "Even  in  tl 
cases."  he  continues,  "nature  sometimes  succeeds  in  limiting  the  inflammation 
to  a  part  of  the  right  side:  but  it  is  at  other  times  diffused  over  the  whole  of 
the  abdomen,  is  accompanied  by  symptoms  of  the  most  serious  nature,  and 
quickly  proves  fatal. " 

Richard  Bright  and  Thomas  Addison,  in  the  "Elements  of  the  Practice 
of  Medicine."  have  left  us  an  admirable  presentation  of  the  subject,  opening 
up  in  the  clearest  manner  the  whole  realm  of  affections  of  the  appendix;  and  I 
wish  space  permitted  me  to  quote  the  entire  six  pages  of  their  work  devoted 
to  ''Inflammation  of  the  Cecum  and  Appendix  Vermiformis."  "That  portion 
of  the  intestine,"  they  say,  "which  is  lodged  in  the  right  iliac  region  is  fre- 
quently the  seat  of  inflammation.  The  history  of  the  affection  is  often  as 
follows:  The  patient  has  complained  more  or  less  for  some  time  past  of  pain 
or  uneasiness  in  the  part,  increased  on  exertion  or  after  neglect  of  the  bowels 
or  excess  in  eating  or  drinking:  ....  after  some  unusual  exposure  to 
cold,  or  some  long  walk,  or  other  over-exertion,  he  has  been  suddenly  seized 
with  rigors,  chills,  and  sometimes  with  sickness  and  violent  vomiting.  The 
pain  and  tenderness  become  excessive,  and  extend  to  the  neighboring  parts  of 
the  abdomen.  A  hardness  and  tumefaction  are  soon  very  evident  to  the  hand 
in  the  part  first  affected;  this  continuing,  general  symptoms  of  peritonitis  often 
take  place,  and  terminate  fatally.  "  The  formation  of  abscess  is  noted,  opening 
of  its  own  accord  or  assisted  by  the  lancet,  securing  a  discharge  of  ill-conditioned 
pus  soon  mingled  with  fecal  matter. 

"From  numerous  dissections  it  is  proved  that  the  fecal  abscess  thus  formed 
in  the  right  iliac  region  arises,  in  a  large  majority  of  cases,  from  disease  set  up 
in  the  appendix  ceci.  It  is  found  that  this  organ  is  very  subject  to  inflammation, 
to  ulceration,  and  even  to  gangrene;  and,  moreover,  that  it  is  occasionally 
thickened  and  ulcerated  from  tubercular  deposits."  "This  little  worm-like 
body  is  often  detected  in  the  midst  of  the  abscess,  with  a  perforation  at  its 
extremity,  or  by  ulceration  higher  up  in  its  parietes,  a  considerable  portion  of 
it.  nearly  or  entirely  separated,  is  found  in  a  disorganized  condition  among 

the  pus  and  feces  which  fill  up  the  abscess In  a  smaller  number 

of  instances  the  cecum  itself  is  found  inflamed  and  ulcerated,  and  extensively 
implicated  in  the  abscess,  in  a  way  which  shows  that  the  appendix  had  little 
to  do  with  the  disease." 


16  HISTORY. 

How  clear  and  comprehensive  are  the  following  remarks  upon  "exciting 
causes":  "It  is  possible  thai  the  secretions  of  the  appendix  itself  may  some- 
times become  diseased,  and  give  rise  to  inflammatory  action  in  the  part;  some- 
times we  can  plainly  discover  thai  stricture,  amounting  even  to  occlusion  of 
the  cavity,  has  taken  place,  so  thai  the  extremity  has  been  distended  with 
its  own  secretions;  and  this  may  plainly  give  rise  to  inflammation ;  and  at  other 
times  we  find  little  oval  masses  of  feces  impacted  in  the  canal,  which  have 
pretty  obviously  produced  the  irritation;  sometimes  a  foreign  substance,  as  a 
cherry-stone  or  other  >fc<\.  has  been  detected  in  the  appendix,  but  one  of  the 
most  common  causes  is  undoubtedly  the  formation  of  a  peculiar  concretion 
which  is  moulded  to  the  extreme  cavity  of  the  canal,  and  which  is  composed 
of  coats  or  layers  of  the  earthy  phosphates,  with  occasional  alternate  layers 
of  animal  secretion  or  of  feculent  matter." 

As  to  diagnosis,  "the  situation  of  the  abscess  in  the  righl  iliac  fossa  will 
often  sufficiently  point  out  the  probability  of  it-  nature":  but  in  some  cases 
difficulties  arise,  "because,  owing  to  the  occasional  burrowing  of  the  abscess, 
it  may  become  most  prominent  at  some  distant  part.'' 

In  the  treatment  it  is  advised  to  unload  the  bowels  by  mild  but  effective 
purgatives,  assisted  by  injections  of  soap  and  water,  or  gruel,  or  other  bland 
liquids,  so  as  to  empty  completely  the  large  intestine.  "At  t  lie  same  time, 
we  must  endeavor  to  disturb  the  pari  as  little  as  possible";  for  the  contents 
of  the  intestine  or  of  the  abscess  may  become  extravasated  into  the  peritoneal 
cavity,  if  violence  is  done  in  our  manual  examination.  "We  must  always 
hold  in  mind  that,  though  our  first  objeel  musl  be  to  allay  the  inflammation 
so  as  t"  prevent  the  formation  of  an  abscess,  yet  much  more  frequently  we  -hall 
be  called  upon  to  prevent  an  ulceration  ami  abscess,  which  are  inevitable, 
from  doing  essential  and  extensive  mischief."  Is  not  this,  we  may  ask.  an 
almost  perfect  presentation  of  the  status  of  the  problem  to-day.  over  sixty 
years  after  these  lucid  remarks  were  penned?  With  what  insight,  with  what 
perspicacity,  did  these  great  English  masters  of  our  art  portray  to  an  ante- 
cedent generation  the  outlines  of  the  affection  which  became  the  malady  pnr 
ce  of  the  end  of  the  century!  Had  not  vague  speculation  and  a  false 
nomenclature  stepped  in  to  alter  the  masterly  outlines  here  given,  who  can  sax- 
how  different  the  history  of  appendicitis  might  have  been! 

Johx  Burne,  physician  to  the  Westminster  Hospital,  contributed  two 
papers  in  1X37  and  1839  to  the  Medical  and  Chirurgical  Tran  actions,  treating  of 
disease  in  the  cecum  ami  appendix.  These  communications  have  always 
received  much  consideration,  and  Burne's  name  has.  in  consequence,  been 
closely  associated  with  the  earliest  literature  of  appendicitis.  A  dispassionate 
consideration  of  his  work  at  the  present  time,  however,  shows  that  its  value 
has  been  greatly  overestimated.  His  undertaking,  he  says,  is  due  to  the  fact 
that  disease  of  the  appendix  had  hitherto  received  no  systematic  consideration. 
showing  that  he  was  not  aware  of  the  French  writers  who  had  made  such  ex- 


BDRNE.       RICHARDS.  17 

tensive  contributions,  nor  does  he  seem  to  have  been  familiar  with  the  work 
of  his  own  countrymen.  He  refers,  indeed,  to  no  one  but  Meniere,  whose  work 
is  perhaps  of  the  least  value.  He  fails  to  discriminate  between  disease  of  the 
cecum  and  disease  of  the  appendix,  and  do  definite  conclusions  can  be  drawn 
from  his  cases,  for  even  when  an  autopsy  was  made  he  often  neglected  to 
mention  the  appendix  at  all!  He  offers  no  valuable  suggestions,  he  lacks  every 
quality  of  the  seer,  and  even  hindered  progress  by  introducing  such  a  misleading 
term  as  "t  u  phi  o-e  n  t  e  r  i  t  is  ."  I  have  had  occasion  to  note  already  the 
harm  done  to  progress  by  a  bad  nomenclature,  and  I  am  sorely  tempted  here  to  a 
short  digression  to  consider  the  question  so  often  asked :  "  What  is  in  a  name? 
Everything!  The  whole  history  of  medicine,  age  after  age,  has  been  dominated 
by  mere  names.  A  false  name,  conveying  a  wrong  impression,  once  given 
in  any  new  field,  in  the  early  days  of  investigation,  opens  up  a  path  of  error  along 
which  men.  in  their  eagerness  to  follow,  tumble  over  one  another  like  sheep, 
and  any  farther  real  advance  is  rendered  impossible  until  the  steps  are  retraced. 
The  unfortunate  term  "  p  er  i  t  y  ph  1  i  t  i  s"  coined  by  Puchelt  and  Goldbeck 
ten  years  before  had  already  diverted  attention  from  the  appendix,  the  real 
point  at  issue,  and  now  "  t  u  p  hlo-enteritis,"  in  line  with  the  extraor- 
dinary gastro-enteric  pathology  of  the  day,  appeared  in  the  field  to  lead 
inquiry  still  farther  astray. 

I  find  myself  at  a  loss  to  discover  any  reasons  why  Burne's  work  has  always 
been  considered  a  classic  in  the  literature  of  appendicitis:  1  believe  the  notice 
it  attracted  was  largely  accidental,  and  due  partly  to  its  appearance  in  a  well- 
known  periodical.  The  same  reasoning  accounts  for  the  frequent  reference 
to  Grisolle's  paper  on  "Tumeurs  Phlegmoneuses,"  in  the  Archives  <!<'>it'r<i!<:i  de 
medecine,  for  1S37.  Though  Grisolle,  like  Burne,  is  often  quoted  with  defer- 
ence, a  careful  perusal  shows  that  his  work  is  almost  valueless,  as  he  sees  no 
reason  for  distinguishing  between  tumors  in  the  right  and  left  iliac  fossa',  nor 
does  he  exclude  abscesses  consequent  upon  the  puerperal  state. 

Among  the  briefer  reports  in  the  current  literature  of  this  period  is  one 
which  especially  deserves  the  attention  of  our  American  surgeons,  because  it 
is,  as  far  as  I  can  ascertain,  the  first  instance  of  disease  of  the  appendix  reported 
in  the  United  States. 

"Wolcott  Richards,  of  Cincinnati,  in  September,  1S37.  published  a  case 
of  perforation  of  the  appendix  confirmed  by  autopsy.  The  patient,  a  man 
thirty-five  years  of  age,  had  a  distinct  chill,  followed  by  fever,  but  without 
pain  in  the  abdomen  or  vomiting.  For  thirteen  days  he  improved  under  treat- 
ment, consisting  mainly  of  calomel  and  light  diet,  but  on  the  fourteenth  day 
he  was  found  in  a  state  of  collapse,  which  came  on  twelve  hours  before:  his 
attendant  declared  that  a  short  time  before  the  change  occurred  he  had  eaten 
imprudently  of  fruit.  He  died  on  the  fifteenth  day.  without  a  diagnosis  having 
been  made.  At  the  autopsy  a  general  peritonitis  was  found  with  recent  adhe- 
sions, while  the  pelvis  was  filled  with  fecal  matter  issuing  from  a  large  ragged 
2 


18  HISTORY. 

perforation  in  the  vermiform  appendix.  Dr.  Richards  comments  upon  the 
strange  facl  thai  not  only  vomiting  bul  abdominal  pain  and  tenderness  were 
absent  during  the  entire  illness;  only  after  the  final  change  for  the  worse  took 
place  was  there  extreme  tenderness  over  the  hypochondriac  region  together 
with  slight  distention. 

Dr.  Thaddeus  Reamy,  of  Cincinnati,  informs  me  that  Dr.  Richards  was 
born  in  New  London,  Connecticut,  in  1803,  and  studied  medicine  in  the  office 
of  Dr.  North,  of  New  London,  in  the  Yale  Medical  School  in  L828;  in  this  year 
he  went  to  Cincinnati,  where  he  enjoyed  a  large,  lucrative  practice  for  thirty 
years,  greatly  beloved  both  by  patients  and  the  medical  profession.  His  death 
occurred  in  New  York,  in  1871,  due  to  a  sarcoma  of  the  base  of  the  brain. 

Edward  11  vllowell,  of  Philadelphia,  in  May,  1838,  reported  a  similar  case. 
The  patient,  a  girl  of  nine,  in  poor  health  for  some  weeks  and  troubled  by  a  per- 
sistent cough,  complained  of  pain  in  the  right  iliac  fossa,  and  a  physician,  with- 
out seeing  her,  prescribed  three  compound  cathartic  pills,  which  acted  violently. 
Dr.  Ilallowell,  visiting  her  the  next  day,  found  a  distinct  tumor  in  the  right 
iliac  fossa,  exquisitely  tender  on  pressure;  there  was  meteorism  and  a  dark 
vomit,  which  continued  until  death  the  next  day.  The  autopsy,  attended 
by  I>rs.  Warrington,  Pearce,  Pepper,  and  Ilallowell,  showed  tuberculosis  of 
the  right  lung,  general  peritonitis,  and  an  appendix  firmly  adherent  to  the 
caput  coli,  with  a  small  perforation  at  its  base  about  two  lines  in  diameter. 
The  mesenteric  glands  near  the  appendix  were  enlarged  and  tuberculous,  and 
there  were  tuberculous  deposits  elsewhere  in  the  intestines.  "The  local  peri- 
tonitis, "  the  writer  remarks,  "  was  no  doubt  of  long  standing,  its  exciting  cause 
was  somewhat  doubtful;  the  probability,  however,  is  that  in  consequence  of  a 
deposit  of  tuberculous  matter  and  the  consequent  softening,  an  ulceration 
of  the  coats  of  the  appendicula  was  induced,  but  the  opening  being  minute  and 
the  contents  of  the  appendicula  small  in  quantity,  the  inflammation  was  not 
sufficient  to  give  rise  to  symptoms  of  an  acute  character,  and  it  was  not  until, 
by  the  action  of  drastic  medicines,  the  secretions  from  the  mucous  cryptffl  of 
the  intestines  were  greatly  augmented,  and  subsequent  violent  efforts  of  the 
bowel  induced,  that  the  contents  of  the  bowel  found  their  way  into  the  cavity 
of  the  peritoneum,  giving  rise  to  the  acute  symptoms  we  have  detailed,  and 
causing  death  in  a  few  hours.'' 

These  are  the  only  cases,  with  four  exceptions,  appearing  in  the  United  States 
for  a  period  of  nearly  twenty  years.  In  the  following  decade  a  case  was  re- 
ported, I  believe  for  the  first  time,  in  Italy,  when  Carlo  Vecchi,  of  Milan, 
published  a  paper  in  lsls  entitled  "  Peritonitis  diffuse  deW  appendice  verfniformi 
ceci."  The  writer  begins  by  saying  that  he  does  not  think  lie  goes  too  far  in 
expressing  the  opinion  that,  for  Italians,  the  condition  he  describes  appears  as 
a  new  disease.  Then,  after  a  short  and  incomplete  account  of  the  literature  of 
the  subject,  he  cites  two  cases,  one  in  his  own  practice,  another  (in  a  foot-note) 
related  to  him  by  a  physician  who  was  present  at  the  autopsy  upon  Yecchi's 


VOLZ.  19 

own  patient.  This  second  case  is  apparently  a  perforation  of  the  appendix  occur- 
ring in  typhoid  fever.  The  paper  is  a  creditable  first  effort  in  a  country  where 
disease  of  the  appendix  had  hitherto  received  no  attention. 

Yolz,  in  1S4G,  published  what  is  undoubtedly  the  most  important  con- 
tribution to  our  subject  for  a  period  of  two  decades.  I  have  purposely  deferred 
noticing  this  work  among  the  German  dissertations,  as  its  importance  entitles 
it  to  special  consideration  in  its  own  time  and  place.  Writing  under  the  cap- 
tion "Die  durch  Kothsteine  bedingte  Durchbohrung  des  Wurmfortsatzes  die  hdufig 
verkannte  Ursache einer  gefahrlichen  Peritonitis  undderen  Behandlung mil  Opium,  " 
the  avowed  purpose  of  his  thesis  is  to  insist  upon  the  benefit  derived  from  the 
opium  treatment  in  perforations  of  the  appendix.  His  views  on  this  particular 
point  will  be  more  appropriately  considered  elsewhere  (see  page  oil);  in 
the  present  connection,  I  am  chiefly  concerned  with  his  work  as  a  systematic 
contribution  to  the  subject  in  its  general  relations.  Yolz,  after  citing  three 
eases  in  which  post-mortem  examinations  revealed  the  presence  of  fecal  concre- 
tions in  the  appendices  of  patients  dying  from  other  causes,  then  gives  a  list 
of  thirty-eight  cases  in  which,  after  a  fatal  illness  characterized  by  symptoms 
of  abdominal  inflammation,  the  vermiform  appendix  was  found  perforated  by 
a  fecal  concretion,  some  of  them  occurring  in  his  own  practice.  He  is  doubtful 
whether  perforation  of  the  appendix  ever  occurs  (exclusive  of  cases  resulting 
from  tuberculosis  and  typhoid  fever)  from  any  other  cause  than  a  fecal  con- 
cretion, so  that  he  devotes  his  close  attention  to  the  study  of  these  concretions, 
dividing  them  into  three  classes:  of  soft,  hard,  and  medium  (halb-feste)  con- 
sistency. He  notes  the  fact  thai  concretions  greatly  resemble  fruit  stones,  and 
therefore  are  often  taken  as  such:  a  chemical  analysis,  however,  proves  that 
they  are  composed  of  organic  matter  and  salts.  Yolz's  account  of  the  natural 
history  of  appendicitis  is  perhaps  the  most  thoughtful  and  comprehensive 
treatment  of  the  subject  up  to  his  time.  He  here  points  out  that  the 
condition  known  as  "perityphlitis"  is  not  primar  y. 
but  consecutive  to  inflammation  of  the  appendix 
vermiformi  s.  He  further  distinguishes  p  1  a  i  n  1  y  b  e  t  w  e  e  n 
suppurative  and  non-suppurative  f  o  r  in  s  o  f  a  p  p  e  n- 
d  i  c  i  t  i  s,  dividing  the  s  u  p  p  u  r  a  t  i  ve  for  m  s  into  t  w  o 
classes,  one  in  which  the  pus  discharges  i  n  t  o  t  h  e  a  1 1- 
d  o  in  i  in  1  cavity,  exciting  a  general  p  e  r  i  t  o  n  i  t  i  s,  a  n  d 
another  in  w  h  i  c  h  the  abscess,  circumscribed  b  y  a  d  h  e- 
s  i  o  n  s,  burrows  in  different  directions  according  to  the 
efficiency  of  this  protective  barrier  in  limiting  the  extension.  Yolz  believes 
that  the  prognosis  is  favorable  if  only  the  opium  treatment  is  followed  out.  and 
he  insists  that  constipation,  the  common  concomitant  <<i  the  disease,  favors 
recovery  and  should  be  encouraged  by  every  possible  means. 

The  antiphlogistic  treatment  in  vogue.  Yolz  characterizes  as  irrational  and 
brutal,  expressing  the  hope  that  the  day  will  come  when  the  principle  of  rest  for 


20 


HISTORY. 


the  intestines,  in  cases  of  inflammation  of  the  appendix,  secured  by  means  of 
opium,  will  be  as  clearly  recognized  as  the  same  principle  universally  used  for 
a  broken  leg  when  it  is  encased  in  splints,  a  happy  parallel,  which  he  makes  all 
the  more  striking  by  carrying  it  oul  in  some  detail  with  both  ingenuity  and 
humor. 

"Nehmen  wir  einmal  an,  ein  Arztbesassi  ueber  den  ursdchlichen  Zusammen- 
hang  der  ZufdUe  eines  Beinbruchs  eben  so  geringe  Kenntniss,  als  ueber  den  der 
Zufdlle  unsrer  Krankheit,  welche  er  lege  artis  mil  Calomel  behandelt,  und  wende 
bei  der  Beurtheilung  derselben  das  ndmliche  Raisonnemenl  an,  welches  ikn  bei  der 
rationellen  Behandlung  dieser  Peritonitis  leitet,  so  werden  wir  erstaunen  iiber  die 
Heilmethode  des  Beinbruchs.  Es  wird  uns  absurd  erscheinen  bei  der  Fractur, 
was  bei  der  Peritonitis  fur  ratwnell  giU. 


••  li<  inbruch. 
"  Kin  <jt  sundt  r  Mi  usrli  i  mpfindt  l  plotzlich 
nach  i  im  m  mechanischt  n  Eingriff  (Fall) 
i  in,  a  Schmerz  im  Fuss, .  und  kann 
seildem  nicht  mehr  gehen  noch  stehen. 
Ohm  die  Ursacht  tu  erkennen,  urtheili 
der  Arzt:  so  langt  der  Mensch  gehen 
konnte,hatti  er  keine  Schmerzen,  sObald 
er  mi)  ili  n  Fussen  steht  und  geht, 
werden  du  Schmerzen  aufhoren.  Also: 
er  wird  mit  der  Peitsche  aus  dem  Bette 
gt  inilii  n.  und  mit  Gt  wall  auj  dv  Fusse 
gestellt.  Der  Erfolg  ist:  du  Schmerzen 
steigem    sich,    und   der    Kranke   kann 

lllldl     llivlll    l/l  III  II  . 


"Peritonitis  durch  Perforation. 

Ein  <i<  sundt  r  Mi  nsch  t  mpfindt  I  plotzlich 

nach  einer  mechanischen  Veranlassung 

(korperlicfu   Bewegung)  einen  Schmen 

mi  l.i  iln.  iiml  hut  si  ih li  in  Verstopfung. 
(thin  die  Ursache  der  Krankheit  :u 
i  rfo  urn  a .  a rili i  ill  ili  r  .  1  rzt:  So  lange  <l<  r 
Mensch  Stuhlgang  hatte,  hatti  er  keine 
Schmerzen,  sobald  dit  Verstopfung  be- 
seitigt  ist,  werden  die  Schmerzen  auf- 
horen. Also:  Alijiilininlli I.  Calomel. 
I  >ir  Erfolg  ist:  dii  Schmerzen  steigem 
sich,  mill  is  tnll  doch  kein  Stuhlgang 


" Denken    wir   mis  andrerseits  beide  Kmnkhriten  crkannt  und  l>ehandelt,  die 
tinr  mil  ih  in  chirurgischen    Verband,  die  andere  mit  Opium,   mid  milium    wir 

didiri    mi.  die    mdirn     lli.ii  li  n  in/  des    \' erlin  lilies   mid  seine   ]]' irksn mhlit  :ur  I'nictur 

sei  uns  n'ir  ebenso  oberfldchlich  bekannt,  wie  die  des  Opiums  ~ur  Peritonitis,  so 
erhalten  wir  folgende  Parallele. 


'Der  Arzt  erkennt  ids  UrsacJu  des 
Schmerzes  und  des  Unvermogens,  :» 
gehen,  einen  Beinbruch.  Er  wendet 
Mittel  me  mil-Ill  dieses  Unvermogen 
noch  steigem,  er  bindet  il<  n  Fuss  und 
din  Kranken  im  Beth  fest.  Wdhrend 
dis  Gebrauchs  dieses  Mittels  verliert 
sich  der  Schmerz,  und  das  Vermogen, 
zu  gehen,  stelti  siclt  nach  und  nach   von 


'Der  Arzt  erkennt  ids  Ursache  des 
Schmerzes  und  der  Verstopfung  eint 
durch  Perforation  eines  Darms  bedingte 
Peritonitis.  Er  wendet  ein  Mittel  an, 
welches  diest  Verstopfung  noch  steigert, 
Opium.  W'nhri  ml  ih  s  Gebrauchs  dieses 
Mittels  verliert  sich  der  Schmerz,  und 
der  Stuhlgang  stellt  sich  von  selbst 
wieder  ein.      Der  Kranh   verlangt  auf 


VOLZ.       KOKITAXSKY.       HANCOCK.  21 

selbst  wieder  ein.     Der  Krarike  verlangt         den   Nachtstukl,    ohm    (lurch    Calomel 
aus   dem   Bctte,  ohne  mit  der  l'<  itsche  dazu  gezwungen  zu  werden. 

getrieben  zu  werden. 

"  Moge  die  Zeit  nicht  rnehr  aUzufeme  sein,  in  welcher  es  uns  vergonnt  ist,  die 
Wirkungen  der  Arzneimittel  auj  die  Krankheit  ebenso  Mar  einzusehen  als  uns 
jetzt  die  Wirkung  des  chirurgischen  Verbands  auj  einen  Beinbruch  deuilich  vor 
Augen  liegt. " 

In  conclusion  Yolz  makes  some  sagacious  and  far-sighted  remarks  on  peri- 
tonitis in  general.  In  his  opinion,  almost  all  inflammations  of  the  peritoneum 
have  their  origin  in  injuries  or  displacements  connected  with  the  abdominal 
organs,  and  of  all  org  a  n  s  t  h  e  a  p  p  e  n  d  i  x  is  oftenest  at 
f  a  u  1  t.  He  maintains  that  the  so-called  idiopathic  peritonitis 
is  si  m  p  1  y  one  i  n  w  h  i  c  h  our  knowledge  is  insufficient 
to  show  us  its  local  starting-point.  Many  such  cases,  for- 
merly considered  spontaneous,  he  says,  have  been  shown  at  the  time  of  writing 
to  have  a  "mechanical  origin, "'  that  is  to  say,  they  proved  to  be  consequent  on 
injury  to  the  peritoneal  surface  resulting  from  morbid  conditions  in  the  organs 
which  it  covers,  and  he  believes  that  in  the  future  most,  if  not  all,  inflammations 
of  the  peritoneum  will  prove  to  be  of  this  kind.  Furthermore,  he  is  convinced 
that  a  perforation  is  the  exciting  cause  in  the  majority  of  cases;  and  if  this  fact 
is  not  discovered,  it  is  because  it  is  not  looked  for.  His  own  pregnant  words 
are  as  follows:  " Es  ist  durchaus  nothwendig  dass  jede  Section  von  Peritonitis 
mit  der  grossten  Genauigkeit  augestelU  werde,  dass  idle  mil  Bauchjell  ueberzogenen 
Organe  sorgfaltig  untersucht  und  beschrieben  werden,  zum  Beioeis,  dass  keines,  auch 
nicht  der  Wurmfortsatz,  ubersehen  warden  ist.  Denn  es  ist  mehr  als  wahrscheinlich, 
dnss  in  mehreren  mitgetheiUen  Fallen,  welche  noch  als  Beweise  jiir  die  Haufigkeii 
der  spontanen  Peritonitis  aufgefuhrt  werden,  nur  desshalb  eine  Perforation  nicht 
gefunden  wurde,  iceil  nach  dem  Wurmfortsatze  gar  nicht  geforscht  warden  war." 

Rokitansky's  work  on  pathological  anatomy,  appearing  in  1842,  contains 
a  brief  but  excellent  section  upon  the  appendix,  and  probably  represents  the 
earliest  systematic  consideration  of  this  organ  from  a  purely  pathological  stand- 
point. Rokitansky  also  for  the  first  time  describes  the  dropsical  condition  known 
as  hydrops  processus  vermiformis,  or  the  cystic  appendix.  "The  vermiform 
appendix,"  he  says,  "is  thus  metamorphosed  into  a  hydropic  capsule  which  in 
the  course  of  time  certainly  may  become  the  seat  of  inflammation  resulting  in 
ulceration  and  perforation." 

Haxcock,  a  London  physician,  in  the  year  1848  operated  for  disease  of  the 
appendix  as  such.  Incision  for  the  relief  of  a  manifest  tumor  in  the  right  iliac 
fossa  had  long  been  practised,  but  Hancock  took  the  first  decisive  step  in  the 
direction  of  our  modern  methods  when  he  published  in  the  Lancet  for  1848  the 
account  of  a  case  in  which  he  operated  successfully  after  making  a  diagnosis  of  in- 
flammation of  the  appendix  before  any  evidence  of  fluctuation  could  be  made  out. 


'_'L'  HISTORY. 

During  the  early  part  of  the  fifth  decade,  between  1840  and  1850,  the  vermi- 
form appendix  became  the  theme  of  frequent  discussions  in  the  pathological 
societies  in  Great  Britain  and  in  the  United  States,  resulting  in  the  publication 
of  a  number  of  isolated  eases. 

Bamburger,  the  author  of  a  series  of  short  papers  in  the  Medizinische 
Zeiiung  for  1858,  is  given  much  prominence  by  German  writers  aboui  this 
time,  but  when  his  work  is  contrasted  with  that  of  others  <>f  the  same  date  its 
value  seems  to  have  been  overestimated.  The  author  even  goes  hack  to  the  old 
theory,  that  the  anatomical  characteristics  of  the  intestinal  canal  are  responsible 
lor  tumors  in  tin'  right  iliac  fossa,  by  causing  a  stercoral  typhlitis  with  perfora- 
tion, and  it  is  evident  from  this  fact  alone  how  far  his  views  were  behind  those 
of  Volz,  writing  twelve  years  before. 

George  Lewis,  of  New  York,  in  the  late  fifties,  issued  a  paper  in  the  New 
York  Medical  Record,  deserving  of  our  particular  attention,  because  he  has  there 
gathered  together  the  results  of  the  slow  evolution  of  our  knowledge  up  to  that 
date  i  ls."iii).  and  because  it  constitutes  the  first  systematic  contribution  to  the 
literature  of  the  vermiform  appendix  appearing  in  the  United  States  of  America. 
For  insight  and  for  clearness  of  exposition,  Dr.  Lewis's  work  must  be  classed 
with  that  of  Melier  in  is.'?,  and  that  of  Volz  in  I s H>,  an  international  tripos, 
supported  by  a  German,  a  Frenchman,  and  an  American,  and  representing 
the  most  forcible  and  comprehensive  contribution  offered,  up  to  the  new  epoch 
created  by  Fitz  in  L886.  Lewis's  paper,  originally  read  before  the  Society  of 
Statistical  Medicine,  tabulates  forty-seven  cases  of  disease  in  the  appendix, 
collected  from  the  literature.  The  statistical  aspect  of  his  work  attracted  so 
much  attention  on  the  part  of  his  reviewers,  that  the  notion  became  and  remained 
current  that  he  offered  in  it  little  more  than  an  able  statistical  contribution,  and  in 
consequence  his  admirable  analysis  of  his  cases  has  been  persistently  overlooked. 
I  am  happy,  in  giving  a  brief  abstract  of  this  paper,  to  be  able  both  todo  justice 
to  its  able  writer  and  to  give  a  concise  present  men!  of  the  status  of  our  know  ledge 
at  this  critical  period,  so  near  the  turning-point  of  the  history  of  our  subject. 

Dr.  Lewis  wrote  under  the  caption  ".1  statistical  contribution  to  our  knowl- 
edge of  ab  cess  and  other  diseases  consequent  upon  the  lodgment  o]  foreign  bodies 
in  the  vermiform  appendix,  with  o  table  of  fort;/  rases."  He  declares  that  the 
obscure  nature  of  this  disease,  its  rapid  ami  almost  necessarily  fatal  termination, 
invest  it  with  a  peculiar  interest  to  the  physician,  and  render  it  of  vital  impor- 
tance to  the  patient.  He  shows  a  clear  perception  of  relative  values  when,  in 
speaking  of  (iiisolle's  paper  on  "Phlegmonous  tumors  in  tin'  right  iliac  fossa," 
he  points  out  that  this  collection  of  seventy  cases  includes  tumors  in  the  left 
fossa  as  well  as  in  the  right,  ami  confuses  those  dependent  on  the  puerperal 
state  with  those  resulting  from  disease  of  the  appendix,  pointing  out  that  "con- 
elusions  drawn  from  cases  so  diverse  in  their  origin  and  history,  instead  of  throw- 
ing light  upon  any  particular  class,  only  increase  the  general  embarrassment 
and  leave  the  practitioner  in  doubt  with  regard  to  the  whole." 


LEWIS.  23 

Very  satisfactory  for  such  a  date  are  his  declarations  regarding  foreign  bodies, 
which,  entering  the  appendix,  may  remain  an  indefinite  time  without  causing 
inconvenience.  When  a  foreign  body  proves  a  source  of  irritation,  it  excites 
catarrhal  inflammation  of  the  mucous  membrane,  which  in  turn  produces 
thickening  of  its  coats  and  finally  ulceration.  The  interruption  of  the  circulation 
may  produce  strangulation  of  its  terminal  extremity.  This  in  turn  may 
be  followed  by  discharge  of  the  body,  in  which  case  the  a  p  p  e  n- 
d  i  x  p  a  r  t  i  all  y  o  r  c  o  m  pi  e  t  e  1  y  s  h  r  i  v  e  1  s  u  p,  f  o  r  in  i  n  g  an 
opaque  ligamentous  cord  or  band.  When  the  foreign  body 
produces  occlusion,  this  may  be  confined  to  the  point  of  attack  or  the  terminal 
extremity  may  become  gangrenous,  and  if  sloughing  occurs,  the  contents  of  the 
cecum  are  discharged  into  the  peritoneal  cavity.  In  other  cases  the  distention 
of  the  mucous  membrane  by  its  own  secretions  results  in  the  formation  of  a 
dropsical  sac.  When  once  the  perforation  is  complete,  general  peritonitis  will 
supervene  unless  the  discharge  is  circumscribed  by  recent  adhesions,  in  which 
case  the  patient  may  live  for  some  time  (in  one  case  recorded  for  four  years) 
until  the  walls  of  the  abscess  suddenly  give  way. 

The  inflammatory  reaction  is  always  most  intense  in  those  parts  immediately 
contiguous  to  the  diseased  appendix,  and  this  may  result  in  various  complica- 
tions, such  as  rectal  and  vesical  tenesmus,  when  the  appendix  lies  in  the  pelvis 
against  the  bladder,  or  phlebitis  due  to  the  proximity  of  the  diseased  appendix 
to  the  iliac  vein.  lie  further  speaks  of  the  formation  of  a  sinus  opening  at  the 
umbilicus,  as  well  as  of  strangulation  of  the  intestine  from  adhesion  of  the 
appendix. 

Pain,  our  author  says,  is  not  invariably  located  at  first  in  the  immediate 
vicinity  of  the  cecum;  but  sometimes  in  some  other  part  of  the  body,  only 
becoming  deeply  fixed  in  the  right  side  as  the  disease  progresses.  Early  vomiting 
generally  arises  from  an  overloaded  stomach;  later  on  it  is  a  symptom  of  peri- 
tonitis. Diarrhea  may  be  sometimes  present  at  the  beginning,  ami  occasionally 
persists,  but  it  is  usually  followed  by  constipation.  In  the  ileocecal  region  a 
well-defined  tumor  is  not  always  present,  but  inflammation  always  exists  there 
in  its  greatest  intensity,  giving  rise  to  unnatural  fulness  and  hardness. 

There  are  two  kinds  of  causes,  predisposing  and  exciting.  The  variations 
in  calibre  in  the  opening  of  the  appendix  into  the  cecum  were  accurately  noted 
by  himself,  by  inserting  tubes  of  different  sizes.  These  variations  he  considers 
a  predisposing  cause;  the  exciting  cause  is  generally  a  foreign  body.  The  effects 
of  overloading  the  stomach  ami  those  of  external  injury  are  also  considered. 

The  prognosis  is  extremely  unfavorable,  as  only  three  out  of  forty-seven 
recorded  cases  recovered.  The  indications  for  treatment  are  identical  with 
those  in  peritonitis  in  general,  only  the  symptoms  should  here  be  met  with 
more  prompt  and  vigorous  measures.  When  the  abscess  points  at  the  surface 
of  the  abdominal  parietes,  the  propriety  of  making  a  free  incision  to  give  exit 
to  the  pus  becomes  a  question  of  importance. 


_' 1  HISTORY. 

Iii  conclusion  he  says  thai  neither  age,  sex,  constitution,  occupation,  imr 
condition  in  life  confer  immunity  from  this  disease.  At  least  half  the  patients 
were  under  twenty  years  of  age,  and  there  is  no  explanation  for  this  fact  nor 
for  the  greater  frequency  of  the  disease  in  men. 

It  will  be  seen  from  this  brief  rteumi  that  Lewis's  paper  is  by  far  (he  most 
complete  investigation  of  diseases  of  the  appendix  up  to  the  date  of  its  pub- 
lication, ami  shows  a  thorough  knowledge  of  the  subject.  In  one  point,  how- 
ever,  lie   failed   to  display  that    perspicacity  elsewhere  so  manifest:    he  did   not 

recognize  the  true  nature  of  typhlitis,  perityphlitis,  ileocecal  abscess,  cecitis,  and 
especially  "  inflammation  of  the  bowels,  "  that  vague,  comprehensive,  ami  illusory 
term  for  abdominal  inflammations  of  all  sorts,  for  so  many  years  a  source  of 
satisfaction  to  the  patient  and  of  convenience  to  the  physician,  as  well  as  the 
hiding-place  for  ignorance. 

A  perusal  of  contemporaneous  literature  of  other  countries  reveals  the  fact 
that  the  true  nature  of  disease  in  the  appendix  was  at  last  beginning  to  dawn 
upon  the  medical  mind.  HOWARD,  a  distinguished  clinician  in  .Montreal,  in 
1858,  delivered  a  lecture  on  the  subject,  which  was  afterward  published,  under 

the    title    •■Clinical    lecture    on    i  njhnn  unit  inn    and    perforation    of    the    o  /iprnil  i.r 

oermiformis,"  in  the  Montreal  Medical  Chronicle  After  citing  a  case  in  his 
own  practice,  the  writer  remarks:  "This  is  an  instance  of  an  affection  which, 
although  not  very  uncommon,  is  yet  so  infrequent  that  more  than  one  example 
seldom  occurs  in  the  practice  of  a  single  individual,  at  least  in  cities  the  size 
of  Montreal"!  That  the  disease  should  lie  sufficiently  known  to  be  made  the 
subject  of  a  clinical  lecture  is  in  itself  a  sign  of  advance. 

Leudet,  in  the  year  L859,  issued  a  paper  in  the  Archives  gin&rale  de  mMedne, 
incited,  he  says,  by  the  fact  that  the  vermiform  appendix  had  not  as  yet  re- 
ceived systematic  attention  from  physicians.  For  a  period  of  nearly  three 
years  it  had  been  his  custom  to  examine  the  condition  of  the  appendix  at  every 
autopsy  in  his  own  hospital  service,  and  the  results  of  these  investigations  led 
him  to  the  following  conclusion:  "Perforation  of  the  ileocecal 
appendix  is  in  i  t  s  e  1  f  m  o  r  e  c  o  tn  m  on  than  all  o  t  h  e  r 
p  e  r  f  o  rati  o  n  s  o  f  a  n  y  p  a  r  t  oft  h  e  i  n  tes  t  i  n  e  w  h  a  t  e  v  e  r; 
it  at  least  equals  in  f  r  e  q  uen  c  y  all  p  e  r  f  o  rati  o  n  s  of 
the  digestive  c  a  n  a  1  t  a  k  e  n  collective!  y.  "  In  1S24.  Louyer- 
Villermay  had  concluded  his  essay  on  the  same  subject  with  the  question:  "But 
how  can  the  inflammation  of  an  organ  of  such  small  size  and.  above  all,  of  such 
limited  importance  cause  death  so  promptly'?  This  we  cannot  explain.  We  are 
equally  ignorant  whether  disease  of  the  appendix  would  be  always  followed  by 
a  result  as  prompt  and  as  disastrous. "  A  comparison  of  these  two  observations 
shows  us  t lie  progress  of  thirty  years.  Ami  yet,  if  we  recall  the  fact  that  Melierliad 
already  shown  in  1M27  thai  a  chronic  inflammation  of  the  vermiform  appendix 
could  exist,  and  in  turn  become  the  exciting  cause  of  suppurative  tumors  in  the 
right  iliac  fossa,  the  gain  in  the  interval,  considered  as  the  fruitage  of  many 


LEUDET.  25 

acute  minds,  seems  but  small;  it  was  a  real  gain,  however,  for  the  knowledge 
attained  became  now  diffused  upon  a  stable  basis  throughout  the  profession. 
The  obstacles  to  earlier  advance  along  the  right  path  were:  The  force  of 
Dupuytren's  authority;  the  misguidance  of  such  misnomers  as  perityphlitis, 
typhlitis,  and  tuphlo-enteritis;  and,  lastly,  the  absence  of  satisfactory  objective 
proofs  that  the  disease  of  the  appendix  began  in  the  appendix  itself,  and  not  in 
the  cecum. 

Dupuytren  was  now  gone,  having  died  in  1835;  the  bad  nomenclature  was 
beginning  to  be  suspected,  and  the  literature  of  the  period  shows  a  growing 
desire  for  a  better  classification  of  the  diseases  of  the  right  iliac  fossa.  Oppolzek, 
in  1SG3,  proposed  the  name  p  a  r  at  y  phi  i  t  i  s  for  inflammation  of  the  con- 
nective tissue  behind  the  cecum,  ami  suggested  limiting  the  use  of  per  i  t  y  p  h- 
litis  to  inflammation  of  the  peritoneal  coat  of  the  cecum  and  appendix,  and 
using  t  y  p  h  1  i  t  i  s  for  an  inflammation  of  the  bowel  itself;  but  p  a  r  a  t  y  p  h- 
litis  was  an  over-refinement  which  never  came  into  general  use.  The  retard- 
ing influence  due  to  the  persistent  belief  that  inflammation  in  the  right  iliac 
fossa  began  in  the  cecum,  and  then  extended  secondarily  to  the  appendix,  was 
the  natural  outcome  of  evidence  derived  exclusively  from  post-mortem  examina- 
tions, which  in  those  days  were  not  held  until  the  disease  had  advanced  so 
far  as  to  seriously  involve  the  adjacent  parts,  when  the  observers  naturally 
accused  the  larger  division  of  the  intestine  of  primary  disease.  This  fatal 
error  was  finally  laid  in  the  dust  only  by  the  overwhelming  proofs  furnished  by 
surgical  autopsies  in  vivo  held  in  the  earlier  stages  of  the  disease,  which  were 
about  to  begin. 

We  have  now  reached  a  point  in  the  history  of  the  vermiform  appendix 
when  the  reported  cases  of  its  diseases  become  too  numerous  to  investigate 
seriatim;  this  increase  appears  to  be  purely  literary  in  character  and  not 
due  to  the  more  frequent  occurrence  of  the  disease,  whose  true  nature  was, 
year  by  year,  becoming  better  understood,  and  acknowledged  as  the  hitherto 
unsuspected  source  of  a  variety  of  abdominal  ailments.  In  quitting  this  period, 
I  offer  a  tabular  statement  of  the  cases  I  have  found  in  the  hundred  years  between 
that  of  Mestivier  in  1759  and  those  of  Leudet  in  1859;  a  statement  which,  it  it 
is  not  exhaustive,  is  yet,  I  believe,  the  fullest  hitherto  published.  For  example, 
the  forty-seven  cases  published  by  Lewis  in  1856  were  all  this  painstaking  writer 
had  been  able  to  gather,  while  my  table,  covering  hut  four  years  more,  adds 
ninety-four  to  the  list.  The  number  would  be  larger  still,  if  all  cases  not  con- 
firmed by  necropsy  were  not  excluded,  since  no  other  evidence  could  be  accepted 
as  satisfactory  proof  during  this  early  period.  This  precautionary  measure 
has  not,  however,  eliminated  many  instances,  for,  unless  the  case  ended  fatally, 
it  was  rarely  reported.  The  cases  have  been  arranged  in  decades,  with  the 
different  countries  side  by  side,  so  that  the  contribution  of  each  nation  can  be 
appreciated  at  a  glance. 


26 


HISTORY. 


TABLE  SHOWING    NUMBER    OF    CASES    OF    DISEASE    l\  THE   APPENDIX 

REPORTED  IN   DIFFERENT  COUNTRIES  DURING  SUCCESSIVE 

DECADES  BETWEEN   L750  AND  1860. 


1750 

TO 

1760 

1760 

to 

177(1 

1 

17711 
to 
1780 

1780 

lo 

1790 

1790 

to 

1800 

1 
1 

1800 

to 

1810 

1 

1 

1810 

to 

1820 

1 
1 

1820 

In 
1830 

7 
2 

1830 

to 

1840 
2 

8 
12 

2 
24 

1840 

lo 

1850 

9 
8 

26 
2 

in 
2 

57 

1850 

ti. 
1860 

1 

11 

8 
11 

Italy 

United  States   

( lanada        

1 

13 

2 

Total    I  tl  i 

1 

2 

!) 

15 

We  find,  as  we  should  naturally  expect,  that  after  beginning  with  a  few 
scattered  cases,  there  is  a  steady  increase  in  the  numbers  up  to  the  year  1S50, 
but  then  during  the  last  decade  (between  fifty  and  sixty)  a  surprising  decrease 
of  about  twenty  per  cent.  A  closer  examination  shows  that  this  reduction  affects 
Germany  alone,  where  there  is  a  drop  from  twenty-six  cases  to  eleven,  while 
elsewhere  the  number  remains  the  same  or  even  a  little  increased.  This  diminu- 
tion corresponds  to  the  closure  of  the  period  already  alluded  to,  in  which  Ger- 
many offered  more  contributions  than  any  other  country  to  our  knowledge  of 
the  appendix,  and  its  sudden  withdrawal  can  hardly  he  explained  on  other 
grounds  than  the  diverted  interests  due  to  the  well-known  intestine  political 
disturbances  at  that  period.  The  decrease  in  France  between  1830  and  1840,  a 
decade  when  there  are  only  two  cases,  may  perhaps  be  explained  by  the  fact  that 
Grisolle's  publication,  the  largest  and  most  important  during  this  period,  was 
of  so  little  value  in  stimulating  research  that  out  of  seventy  of  his  cases  but  two 
are  sufficiently  trustworthy  to  be  included  in  my  table. 

from  this  date  (1860)  on,  diseases  of  the  appendix  begin  to  become  more  and 
more  a  question  of  surgery. 

Willard  Parker,  of  New  York,  in  1807,  published  four  cases  of  suppuration 
in  the  right  iliac  fossa  arising  from  inflammation  of  the  vermiform  appendix, 
successfully  treated  by  incision  ami  evacuation  of  the  pus.  In  one  case  he 
followed  the  example  set  by  Hancock  twenty  years  earlier  and  made  his  incision 
before  fluctuation  began.  Parker's  operation  will  be  more  fully  discussed  in 
Chapter  III;  it  is  sufficient  to  note  here  that  from  the  date  of  his  teaching 
operative  treatment  of  appendicitis  began  an  evolution  which  ended  in  the 
revolution  of  surgery.  .Most  of  the  valuable  contributions  from  this  date  on 
are  surgical  in  character;  a  few,  however,  still  call  for  notice  before  closing  this 
chapter. 

\V.  T.  Bull,  in  1873.  published  a  paper  on  "Perityphlitis"  in  the  New  York 
Medical  Record,  it  being  originally  an  inaugural  thesis  which  received  the  prize 
offered  by  the  Faculty  of  Physicians  ami  Surgeons  of  New  York  in  1872.  This 
paper,  which  is  an  excellent  one,  was  based  on  an  analysis  of  sixty-seven  cases; 


MATTERSTOCK.       WITH.  27 

thirty-two  of  these  recovered;  in  those  ending  fatally  the  cause  of  death  is  stated 
in  all  but  one.  It  is  interesting  to  contrast  these  cases,  reported  at  a  time  when 
the  disease  ran  its  course  unhindered,  with  those  of  our  own  time,  when  it  is  uni- 
formly cut  short  by  operation.  Of  the  thirty-two  deaths,  thirteen  were  due  to 
exhaustion;  eight  to  peritonitis,  and  six  to  pyemia.  Of  the  remaining  five,  two 
deaths  were  from  hemorrhage  due  to  erosion  of  the  iliac  artery,  one  from  hemor- 
rhage caused  by  an  incision  made  to  let  out  pus,  and  two  from  empyema. 

Matterstock,  in  1880,  published  a  paper  on  "Perityphlitis"  in  the  Hand- 
bitch  der  Kinderkrankheiten.  Without  contributing  anything  new  as  a  matter 
of  research,  Matterstock's  article  did  good  service  by  presenting  a  large  number 
of  cases  gathered  from  literature  and  from  hospital  records.  His  pregnant  open- 
ing words  are:  "By  perityphlitis,  we  understand  that  form  of  circumscribed 
peritonitis  with  the  formation  of  pus  which  develops  in  the  right  iliac  fossa, 
generally  in  consequence  of  ulceration  and  perforation.  We  have  recently 
begun  to  emancipate  ourselves  from  the  idea,  which  has  hitherto  dominated 
us,  that  the  cecum  was  chiefly  concerned  in  the  causation  of  disease  in  the  right 
side  of  the  abdomen.  We  are  now  constantly  obtaining  a  better  knowledge  of 
the  nature  of  disease  in  the  vermiform  appendix,  and  the  more  our  attention  is 
focused  on  the  morbid  processes  affecting  this  tiny  organ,  hitherto  overlooked, 
the  more  frequently  do  we  find  it  to  be  the  chief  if  not  the  only  cause  of  the 
rapidly  fatal  illness  which  we  call  perityphlitis.  " 

This  is  the  first  clear  note  of  a  complete  emancipation  from  the  cecal  theory 
of  inflammatory  disease  in  the  right  iliac  fossa,  and  we  have  at  last  reached  a 
point  when  the  mask  of  "perityphlitis"  was  taken  off,  although  such  is  the  force 
of  habit  that  the  misnomer  continues  in  use  even  to-day.  (See  accounts  of 
King  Edward's  recent  illness.) 

With,  a  Norwegian,  in  1880,  contemporaneously  with  Matterstock,  pub- 
lished a  contribution  to  the  subject,  which  does  credit  to  both  author  and  nation. 
His  title  is  "Peritonitis  Appendicularis,''  and  the  gist  of  his  thought  is  that 
disease  of  the  appendix  is  far  more  important  than  had  been  previously  acknowl- 
edged. With  lays  stress  on  his  p  e  r  s  o  n  a  1  examination  of  the 
records  of  three  hundred  autopsies,  in  which  the  c  o  n- 
d  i  t  i  o  n  of  the  appendix  was  noted;  it  was  found  healthy  in  but 
one  hundred  and  ninety;  in  one  hundred  and  ten  it  was  more  or  less  diseased. 
He  had  also  seen  a  few  cases  of  ulceration  of  the  appendix  followed  by  general 
peritonitis  confirmed  by  autopsy,  and  his  conviction  was  that  the  great  variety 
of  abdominal  affections,  known  under  such  protean  names,  are.  in  reality,  but 
disease  of  the  vermiform  appendix,  which  he  proposes  to  call  by  the  name 
"peritonitis  appendicularis."  Here  we  find  in  extreme  northern  soil  a  model 
contribution  to  our  subject,  leading  observers  back  to  the  source  of  all  accurate 
medical  knowledge,  the  autopsy  table,  an  excellent  purely  objective  statement 
which  no  change  of  time  or  dogma  can  controvert. 

Samuel  Fenwick,  in  the  Lancet  for  1884,  published  a  series  of  clinical  lectures 


28  HISTORY. 

relating  to  cases  difficult  of  diagnosis,  remarking  at  the  outset  thai  "there  are 
some  affections  which  occur  so  rarely  thai  only  a  few  fall  within  the  observation 
of  any  practitioner, "  recalling  the  words  of  Howard,  of  Montreal,  twenty-five 
years  before.  He  strongly  contends  for  a  separate  inflammation  in  the  appen- 
dix, and  emphasizes  the  necessity  of  giving  this  organ  yet  greater  attention, 
for  although  he  still  believes  in  inflammation  of  the  cecum,  he  holds  that 
many  such  cases  are  in  reality  diseases  of  the  appendix.  To  support  this  view, 
he  relates  an  instance  of  a  man  seized  with  a  so-called  "typhlitis,"  from  which 
lie  recovered,  hut  four  years  later  he  was  again  taken  ill,  after  playing  a 
game  of  cricket,  developed  all  the  symptoms  of  appendicitis  and  died.  There 
was  no  autopsy  allowed,  hut  Fenwick  felt  sure  that  death  was  due  to  a  perforation 
of  the  appendix;  and  he  maintains  that  the  diagnosis  between  typhlitis  and 
appendicitis  must  depend  on  the  absence  of  tumor  in  disease  of  the  appendix, 
together  with  the  fact  that  in  typhlitis  the  symptoms  are  comparatively  mild. 

At  length,  in  the  year  L886,  an  article  appeared  which  cleared  up  the  entire 
subject,  and  created  an  epoch  in  medical  and  surgical  history. 

Reginald  Fitz,  of  Boston,  the  author  of  this  paper,  has  done  more  than 
any  single  individual  to  bring  about  a  right  understanding  of  the  morbid  con- 
ditions affecting  the  vermiform  appendix.  In  vain  had  the  little  shafts  nf 
light,  shot  out  from  time  to  time  during  more  than  half  a  century,  sought  to 
dissipate  the  darkness  enveloping  this  subject;  as  long  as  "typhlitis"  and 
" perityphlitis "  reigned  co-ordinate  with  the  unnamed  diseases  of  the  vermi- 
form appendix  all  was  doubt  and  obscurity.  Now  everything  was  to  be  changed, 
and  as  a  tangled  skein  full  of  knots  and  false  clues  yields  at  once  to  the  hand 
which  holds  the  right  thread,  so  the  perplexities,  obstacles,  and  unfounded 
notions  which  hitherto  blocked  the  way,  disappeared  as  soon  as  fitz  supplied 
and  enforced  the  acceptance  of  the  correct  fundamental  fact — that  the  multi- 
farious abdominal  disorders  hitherto  variously  named  were  all  no  more  than 
forms  and  stages  of  inflammation  of  the  appendix.  Finding  his  subject  buried 
under  a  mass  of  inco-ordinated  facts  and  unstable  theories.  Fitz  left  it  clarified 
of  all  obscurity  and  established  upon  a  scientific  basis.  He  declares  at  the  outsel 
that  "even  the  most  recent  systematic  writers  are  by  no  means  agreed  as  to 
the  exact  relation  of  the  cecum  and  that  of  the  appendix  to  peritonitis  and  peri- 
typhlitis. The  vital  importance  of  the  timely  and  appropriate  treatment  of 
the  disease  in  question  is  becoming  more  and  more  apparent.  Such  treatment  is 
often  postponed  till  hopeless,  even  if  its  application  is  at  any  time  entertained. 
.  .  .  .  The  clinician  obviously  recognizes,  as  of  the  chiefest  importance, 
the  parts  to  which  local  treatment  may  be  directly  applied.  His  attention  is 
thus  conspicuously  directed  to  the  cecum,  which  may  be  evacuated,  or  to  the 
perityphlitic  abscess,  which  may  be  emptied.  The  pathologist  looks  for  the 
seal  and  causes  of  the  disease,  and  finds  that  in  most  fatal  cases  of  typhlitis  the 
cecum  is  intact,  while  the  appendix  is  ulcerated  and  perforated.  He  sees  that 
the  so-called  perityphlitic  abscess  is  usually  an  encysted  peritonitis.     Further- 


FITZ.  29 

more,  if  an  abscess  exists  in  the  pericecal  fibrous  tissue,  it  is  in  most  instances 
caused  by  an  inflamed  appendix.  Finally,  if  the  encysted  peritoneal  abscess. 
or  the  abscess  in  the  fibrous  tissue  behind  the  cecum,  does  communicate  with 
the  latter,  such  an  opening  is  usually  the  result,  not  the  cause  of  this  attack." 
Fitz  continues  that  "any  attempt  at  explaining  the  various  results  of  an  inflam- 
mation of  the  appendix  must  necessarily  be  preceded  by  a  statement  of  the 

peculiarities  it  may  present  with  respect  to  structure  and  position for 

variations  in  length,  p  o  s  i  t  i  o  n,  a  n  d  p  a  t  e  n  c  y,  w  h  e  t  h  e  r 
c  o  n  g  e  n  i  t  a  1  o  r  a  c  q  uire  d,  a  re  of  o  b  vi  o  u  s  i  m  p  o  r  t  a  nee 
in  explaining  m  a  n  y  o  f  the  a  p  p  arent  d  i  f  f  e  r  e  n  c  e  s  i  n 
the  clinical  histories  of  typhlitis  and  p  e  r  i  t  y  p  h- 
litis."  "While  the  anatomical  differences  in  different  appendices  had  already 
been  made  a  subject  for  comment  by  many  writers,  this  is  the  first  suggestion 
that  variations  in  the  position  and  structure  of  the  appendix  were  the  real  ex- 
planation of  clinical  peculiarities  which  up  to  this  time  had  been  supposed  to 
indicate  two  morbid  conditions.  These  remarks  are  followed  by  an  analysis 
of  such  anatomical  differences,  together  with  a  description  of  the  part  played 
by  external  violence  and  fecal  concretions.  It  is  during  this  discussion  that 
the  name  "appendicitis"  appears  for  the  first  time,  quite  incidentally  and 
without  any  formal  introduction,  the  writer  speaking  of  perforating  inflam- 
mation of  the  appendix  on  one  page,  and  of  appendicitis  on  the  next,  and  using 
the  terms  interchangeably  throughout  the  rest  of  the  article.  Dr.  Fitz  speaks 
of  the  introduction  of  this  term  in  a  personal  letter,  as  follows: 

"The  word  was  coined  by  me  purely  for  practical  purposes.  I  wished  to 
call  attention  to  inflammation  of  the  vermiform  appendix  as  the  primary  lesion 
and  that  to  which  treatment  was  directly  to  be  applied.  Although  etynio- 
logieally  incorrect,  the  term  was  not  without  analogy — of  those  which  have 
been  offered  in  its  place,  I  much  prefer  epityphlitis,  although  at  the  time  my 
paper  was  written  I  wished  to  discourage  the  prevailing  view  that  the  disease 
in  question  involved  the  cecum  to  any  considerable  extent.  The  subject  is 
now  so  well  understood  that  its  nomenclature  seems  of  minor  importance.  I 
much  prefer  appendicitis  to  Fitz's  disease.  " 

Throughout  the  whole  article  the  various  abdominal  disorders,  typhlitis, 
perityphlitis,  paratyphlitis,  and  others,  which  had  for  years  been  separately 
considered  and  treated,  are  discussed,  and  convincingly  shown  to  be  simply 
varying  manifestations  of  a  morbid  process  originating  in  the  appendix.  "Ster- 
coral cecitis"  is  still  considered  frequent,  although  perforating  ulcer  of  the 
cecum  is  stated  to  be  extremely  rare. 

Finally,  when  the  question  of  treatment  is  broughl  forward,  the  necessity 
for  operative  measures  is  immediately  discussed.  "If,"  says  Fitz,  "after  the 
first  twenty-four  hours  from  the  onset  of  severe  pain,  the  peritonitis  is  evidently 
spreading  and  the  condition  of  the  patient  is  grave,  the  question  should  be 
entertained  of  an  immediate  opening  for  exposing  the  appendix  and  determining 


30  HISTORY. 

its  condition  with  reference  to  its  removal,  tf  any  good  result  is  to  arise  from 
such  treatment,  it  must  be  applied  early."  He  then  reviews  in  a  few  words 
the  different  attempts  at  operative  procedures  which  had  been  made  up  to  that 
time,  and  demonstrates  conclusively  thai  the  date  fixed  by  Parker  for  inter- 
ference, namely,  alter  the  fifth  day.  is  dangerously  late;  the  current  practice  of 
making  it  later  fie  utterly  condemns. 

He  says:    "In  conclusion,  the  following  statements  seem  warranted: 

"The  vital  importance  of  early  recognition  of  perforative  peritonitis  is 
unmistakable. 

"Its  diagnosis  in  must  cases  is  comparatively  easy. 

"It-  eventual  treatment  by  laparotomy  is  generally  indispensable. 

"Urgent  symptoms  demand  immediate  exposure  of  the  perforated  appen- 
dix, after  recovery  from  the  shock,  and  its  after-treatment  according  to  surgical 
principles. 

"If  delay  seems  warranted,  the  resulting  abscess,  as  a  rule  intraperitoneal, 
should  lie  incised  as  soon  as  it  becomes  evident.  This  is  usually  on  the  third 
day  after  the  appearance  of  the  characteristic  symptoms  of  the  disease. " 

Fitz  wrote  two  subsequenl  papers  in  Inns  and  1890,  tor  which  space  permits 
only  an  honorable  mention.  In  all  his  work,  and  especially  that  just  con- 
sidered, we  are  struck  by  the  ease  with  which  questions  previously  perplexed 

are  resolved  by  a   master  hand  into  simplicity  itself.      At    this  dale  the   medical 

profession  stood  in  an  expectant  attitude,  and  it  needed  hut  this  demonstration 
to  force  conviction  and  usher  in  an  era  of  wholesome  activity.  The  time  was 
ripe,  the  man  appeared,  and  surgeons,  needing  bul  the  assurance  of  safety, 
gratefully  accepted  this  transfer  from  the  domain  of  internal  medicine  ami  began 
with  alacrity  to  develop  the  operative  procedures,  which,  in  their  turn  supplying 
further  opportunities  for  investigation,  yielded  more  and  more  definite  knowl- 
edge of  the  morbid  processes  affecting  the  right  iliac  fossa. 


CHAPTER  III. 

HISTORY. 

THE  SURGICAL  HISTORY  OF  DISEASES  OF  THE  VERMIFORM  APPENDIX. 

1886-1904. 

"What  we  wish  to  accomplish  in  tfn  treatment  of  appendicitis  is,  not  to  save  half  of  our 

cases,    nor  four  cases  out  of  five,  but  all  of  them." — (C.   McBurney,    New  York 

Med.  Jour..  1889,  vol.  i.  p.  679. 
"Then  is  only  one  logical  treatment  of  th(  disease,  namely,  tl,<   excision  of  the  diseased 

organ  as  soon  as  tht   diagnosis  is  made." — (A.  Worcester,   Ann.  of  Gyn.  and 

Ped.,  1892,  vol.  v.  p.  449.) 

The  aggressive  surgery  of  the  vermiform  appendix  as  practised  to-day  is 
only  a  development  of  the  past  twenty  years.  Tin'  incision  and  evacuation  of 
old  encysted  collections  of  pus  in  the  right  iliac  fossa,  resulting  from  an  inflam- 
mation in  the  appendix,  was  practised  as  far  hack  as  the  beginning  of  the  Chris- 
tian era.  About  the  year  50  B.C.,  Aret.kts.  in  his  "Cause,  and  Symptoms  of 
Diseasi  s,  "  says  of  abdominal  abscess:  "  But  in  the  viscera  below  the  diaphragm, 
the  liver,  spleen,  and  kidneys,  the  passage  fur  the  matter  is  by  the  bladder,  and 
in  women  by  the  vagina.  And  I  mire  made  an  incision  into  the  abscess  in  the 
colon,  on  the  right  side  near  the  liver,  and  much  pus  gushed  out,  and  much  also 
passed  by  the  kidneys  ami  bladder  fur  several  days."  This  may  have  been  either 
a  large  pyonephrosis  or  a  large  abscess  -tailing  in  the  right  iliac  fossa.  It  is 
said  that  fifty  years  later,  about  1(K)  A. I)..  Soranus  of  Ephesus  evacuated  a 
collection  of  pus  situated  between  the  peritoneum  and  the  intestines,  through 
an  incision  in  the  region  of  the  liver,  after  the  method  of  Erasistratus.*  It  is 
manifest  that  these  efforts  were  but  the  blind  groping  of  the  ancients,  exhibiting 
no  special  insight  nor  calling  for  any  unusual  courage  or  skill. 

After  the  year  1700.  occasional  records  are  found  of  the  evacuation  of  blood 
and  pus  in  the  abdominal  cavity.  The  first  case  in  which  disease  of  the  appendix 
is  clearly  recognized  among  these  and  recorded  is  that  of  Mestivier  in  1759 
(see  Chapter  I.  page  2),  in  a  man  with  a  suppuration  in  the  right  iliac  fossa, 
which  discharged  about  a  pint  of  pus  on  incision;  after  death  a  pin  was  found 
in  the  appendix. 

*"  Causes  and  Symptoms  of  Acute  Diseases."  Bk,  i.  Chap.  9.  p.  312.  Translation  by 
Francis  Adams,  I.I.  D. :  published  by  the  Sydenham  Society,  1856. 

31 


32  HISTORY. 

From  this  date  'IT.V.ii  onward,  tumors  of  the  righl  iliac  fossa  received  in- 
creasing attention.  Their  treatment  by  the  time-honored  incision  a1  the  point 
of  fluctuation  was  recommended  and  practised  by  Dupuytren,  bul  the  notion 
of  incising  right  iliac  tumors  before  any  fluctuation  could  be  detected  did  not 
occur  to  him  or  his  followers,  and  it  was  not  until  L848  that  incision  at  an  earlier 
stage  was  attempted. 

Hancock,  an  English  surgeon,  in  1848  reported  such  a  case  to  the 
Clinical  Society  of  London,  of  so  much  historical  interesl  thai  I  venture  to 
quote  it  somewhat  fully,  and  as  nearly  as  possible  verbatim.  Hancock  begins 
by  observing  that  abscesses  of  the  abdomen  connected  with  the  cecum  or  large 
intestine,  attended  by  fluctuation,  had  from  time  to  time  been  opened,  but  he 
was  not  aware  of  any  instance  in  which  an  operation  had  been  attempted  under 
the  circumstances  aboul  to  be  detailed.  Other  surgeons  had  waited  for  the 
presence  of  fluctuation  to  prove  the  presence  of  matter,  bul  this  case  shows  that 
this  unequivocal  sign  should  not  always  be  waited  for. 

His  patient,  a  married  woman,  thirty  years  of  age,  had  had  had  health 
following  an  injury  to  the  spine,  twelve  years  before.  Since  then,  the  bowels 
never  moved  efficiently  without  an  enema,  and  she  had  suffered  occasional 
attacks  of  pain.  The  present  illness  began  at  the  end  of  her  fifth  pregnancy, 
which  was  characterized  by  incessant  nausea;  she  was  seized  suddenly,  while 
out  driving,  with  an  unusual  dragging  pain  in  her  right  side,  obliging  her  to 
take  to  her  bed  and  to  use  opiates.  Four  or  five  days  later  a  premature  delivery 
followed  of  a  child,  which  lived  hut  a  lew  hours.  The  day  after  delivery, 
while  turning  in  bed,  she  felt  a  severe  pain  ami  snapping  sensation  in  the 
righl  groin,  and  from  that  time  she  suffered  greatly  with  pain  in  that  locality. 
On  the  third  day  a  slight  hard  swelling  could  he  distinctly  traced  high  up  in 
the  inguinal  region.  When  seen  by  Hancock  on  the  seventh  daw  there  was 
intense  pain  in  the  right  iliac  fossa,  and  tenderness  over  the  whole  abdomen 
with  tympanites.  Two  days  later  symptoms  of  general  peritonitis  appeared. 
There  was  a  cord-like  swelling  in  the  inguinal  region  with  thickening  and  harden- 
ing extending  out  toward  the  ilium.  Operation  was  then  proposed,  agreed  to, 
and.  the  patient  being  under  the  influence  of  chloroform,  an  incision  about  four 
inches  long  was  made  from  the  spine  of  the  ilium  above  Poupart's  ligament, 
and  as  close  to  it  as  possible.  Upon  opening  the  abdomen,  a  quantity  of  turbid 
serum  poured  out,  mixed  with  air  bubbles  and  patches  of  false  membrane. 
This  discharge  continued  for  some  time  very  freely,  and  on  the  fifteenth  day 
t  w  o  f  e  c  a  1  C  o  ii  c  r  e  t  ions  w  ere  found  in  the  w  o  u  n  d.  which 
had  been  very  painful.  From  this  date  the  patient  improved,  and  ultimately 
recovered. 

In  the  discussion  following  his  report,  Hancock  contended  that  the  typhoid 
condition  into  which  patients  with  peritoneal  inflammation  fall  did  not  depend 
upon  the  violence  of  the  disease,  but  upon  the  acrid  nature  of  the  effused  fluid, 
the  removal  of  which  he  declared  offered  the  only  chance  of  saving  life;  and  as 


HANCOCK.       GAY.  33 

the  patient  in  this  case  was  so  obviously  sinking,  and  the  previous  treatment  had 
been  of  no  avail,  he  had  proposed  to  make  an  incision  from  the  spine  of  the  ilium 
to  the  inner  side  of  the  internal  abdominal  ring,  over  the  hardened  spot,  so  that 
if  it  were  intestine  or  omentum  it  could  be  freed,  or  if,  as  was  thought  more  prob- 
able, matter  had  collected  in  the  right  iliac  fossa,  it  could  be  let  out,  and  the 
patient  given  a  chance  to  recover.  He  urged  strongly  that  the  fecal  concretions 
found  in  the  wound  were  convincing  evidence  that  the  abscess  had  started  in 
the  appendix.  Judging  from  the  remarks  which  followed,  his  views  made  a 
strong  impression,  but  the  effect  does  not  appear  to  have  outlasted  the  time  and 
place  of  their  presentation,  for  nothing  more  is  heard  of  the  surgical  treatment  of 
such  tumors,  in  the  absence  of  fluctuation,  for  nearly  twenty  years. 

Another  case  of  special  interest,  which  seems  to  have  escaped  our  medical 
historians,  appeared  about  two  years  later  in  a  report  to  the  Pathological  Society 
of  London  for  1850-1851. 

Gay  presented  this  case  under  the  title  "Internal  strangulation  between 
the  appendix  oermiformis,  which  had  become  adherent  to  the  ileum,  and  a  band  of 
false  membrane. "  The  patient,  a  man  of  forty-two,  was  seized  with  severe  pain 
in  the  right  iliac  region  after  lifting  a  heavy  bureau,  accompanied  by  vomiting, 
constipation,  and  signs  of  collapse.  These  symptoms  continued  about  four 
days,  when,  with  a  free  evacuation  of  the  bowels,  convalescence  ensued.  During 
the  succeeding  five  years,  however,  he  had  about  thirty  similar  attacks,  lasting 
from  one  to  four  days,  and  ending  in  the  same  way  in  a  free  evacuation  of  the 
bowels.  The  pain  always  began  on  the  left  side,  and  then  extended  to  the 
right.  The  last  attack  followed  the  usual  course,  until  the  fifth  day,  when  the 
vomiting  was  clearly  fecal.  When  seen  by  Gay,  on  the  afternoon  of  that  day, 
the  abdomen  was  found  hard  and  rather  tumid,  and  pressure  to  the  left  of  the 
umbilicus  and  along  the  left  iliac  fossa  gave  intense  pain,  while  elsewhere  the 
tenderness  was  comparatively  slight.  Around  the  umbilicus  and  over  the  cecum 
there  was  dulness  on  percussion.  Gay  concluded  that  there  was  an  obstruc- 
tion caused  by  some  internal  ring  into  which  the  bowel  had  slipped,  without 
on  this,  as  on  previous  occasions,  being  able  spontaneously  to  free  itself.  Opera- 
tion was  determined  upon,  and  a  five-inch  incision  made  in  the  linea  alba,  expos- 
ing distended  and  intensely  inflamed  intestines  at  the  seat  of  pain,  but  no  obstruc- 
tion. But  when  the  right  iliac  region  was  explored,  about  fifteen  inches  of  flaccid, 
dark  colored  intestine  was  found  to  have  passed  in  behind  an  adherent  vermiform 
appendix.  The  incarcerated  bowel  was  liberated  without  difficulty,  and  fecal 
matter  then  seen  to  pass  on  through;  after  which,  as  the  obstruction  was 
removed,  the  wound  was  closed.  The  patient  came  to,  and  felt  relieved: 
he  was  left  with  strict  injunctions  against  exertion,  but  in  the  temporary 
absence  of  his  wife,  at  four  in  the  morning,  he  rose  from  bed,  fell  to  the  floor. 
and  soon  after  died. 

An  autopsy  was  made,  and  the  small  intestines  found  distended,  congested. 
and  cohering  by  recently  exuded  lymph.  The  strangulation  was  shown  to 
3 


34  HISTORY. 

have  been  cau>ed  by  the  passage  of  loops  of  small  intestine  through  an  opening 
bounded  by  the  appendix,  ileum,  and  cecum.  The  appendix,  which  was  much 
thickened  at  the  tip,  adhered  i<>  the  ileum  above  the  cecum,  forming  a  complete 
ring,  with  the  cecum  mi  the  right,  the  appendix  in  front,  and  the  ileum  on  the 
left  side.  The  small  intestines  below  the  seat  of  constriction  and  the  whole  of 
the  large  intestine  were  contracted,  nearly  empty,  anil  health)-,  hut  above  the 
constricted  portion  the  ileum  was  greatly  distended,  and  its  coats  intensely 
inflamed,  being  in  places  quite  black,  or  sloughing.  Some  distended  convolu- 
tions of  the  small  intestine  overlying  the  cecum  had  yielded  the  dulness  on 
percussion  in  the  right  iliac  fossa.  The  operation  was  manifestly  undertaken 
to  relieve  one  of  the  sequela  of  an  old  appendicitis,  and  is,  I  believe,  the  first 
celiotomy  in  which  the  abdomen  was  opened  and  the  diseased  appendix  exposed 
to  view. 

W'ii.i.mm)  Parker,  of  New  York,  took  the  next  step  in  the  development  of 
the  surgery  of  the  appendix,  in  L867.  His  name  is  so  intimately  associated 
with  this  subject  in  America  that  the  method  he  pursued  became  widely  known, 
and  is  still  called  the  Willard  Parker  operation.  It  was  in  this  year,  L867,  that 
barker  published  four  cases  in  which  he  had  treated  abscess  in  the  right  iliac 
fossa,  consequent  on  inflammation  of  the  appendix,  by  incision  and  evacuation, 
one  dating  as  far  back  as  is  17.  In  the  intervening  years  he  gradually  became 
convinced  that  it  was  not  necessary,  nor  even  desirable,  to  await  fluctuation 
before  making  an  incision,  and  the  last  case  afforded  him  the  opportunity 
of  putting  his  theory  to  a  successful  test.     The  important  object  of  his  writing, 

therefore,  was  to  declare  what  g 1  results  were  likely  to  attend  an  early  incision, 

and  to  counsel  its  wider  adoption. 

He  declares  that:  ''The  matter  of  local  treat  ment  [of  disease  of  the  appen- 
dix] has  attracted  my  attention  for  years.  These  questions  presented  them- 
selves: Are  the  efforts  of  nature  exerted  in  behalf  of  such  a  case,  and  if  SO,  in 
what  way'?  Observation  indicates  the  reply  and  experience  verifies  its  truth. 
Nature  does  labor  in  behalf  of  life  in  two  ways:  (1)  by  means  of  the  wall  of 
false  membranes  which  she  builds  around  the  abscess:  and  (2)  by  the  ulceration 
which  gives  exit  to  the  escape  of  its  contents.  This  being  settled,  it  becomes  a 
question  whether  surgery  might  be  able  to  render  assistance  to  nature  in  this 

work;  and  if  so.  at  what  period  would  assistance  best  come  in To 

lie  successful  it  is  necessary  that  it  should  be  made  neither  too  early  nor  too  late — 
not  before  adhesions  are  fully  formed,  nor,  after  a  short  period,  before  the  maxi- 
mum formation  of  pus  has  been  reached,  that  is,  the  incision  should  be  made 

after  the  fifth  day  and  before  the  twelfth If  no  abscess  has  already 

formed,  in  case  one  should  be  in  process  of  formation,  an  external  opening  would 
tend  to  make  it  point  in  a  safe  direction.  And  even  if  no  abscess  should  form, 
a  free  incision  would  relieve  tension,  thus  adding  to  the  comfort  of  the  patient 
and  in  no  way  prejudicing  his  safety.  One  other  question  remains:  Would 
the  operation  bring  about   a  cure9     Judging  from   the  three  cases   reported 


PARKER.  35 

above,  an  affirmative  answer  seems  certain;  for  these  recovered,  because,  in 
each  one,  nature  had  provided  for  an  external  discharge  of  the  contents  of  the 
abscess,  and  what  nature  provided  in  these  three,  an  operation  would  provide 
in  all  cases. " 

The  case  in  which  these  theories  of  Parker's  were  put  to  the  test  was  operated 
upon  on  the  ninth  day,  when  there  was  an  area  of  circu  in- 
scribed tenderness  in  the  right  iliac  fossa,  but  no 
definite  swelling,  still  less  fluctuation.  An  incision  six 
inches  long  was  made  through  the  skin,  commencing  above  and  about  one  inch 
from  the  anterior  superior  spine  of  the  ilium  and  running  toward  the  symphysis. 
As  soon  as  the  transversalis  muscle  was  reached,  a  tumor  could  be  felt  about 
two  and  a  half  inches  wide,  and  on  introducing  an  exploring  needle  some  thick, 
ill-smelling  pus  gushed  out ;  when  the  sac  was  freely  opened,  about  four  ounces 
of  pus  escaped.  A  tent  was  inserted,  and  the  wound  left  to  heal  by  granulation; 
the  patient  making  a  perfect  recover}-. 

Dr.  Daniel  Stimson,  Professor  Parker's  son-in-law,  writes  me:  "  I  remember 
his  [Dr.  Parker]  speaking  frequently  of  having  been  impressed  by  an  autopsy 
on  a  young  girl,  the  daughter  of  an  old  and  valued  friend,  whose  death  quite 
prostrated  him,  with  the  fact  that  he  must  interfere  surgically,  if  he  had  another 
case  where  the  diagnosis  was  clear  and  when  he  could  operate  beween  the  time 
of  the  walling  in  of  the  abscess  by  peritonitis  and  the  breaking-down  of  the  wall, 
with  the  subsequent  diffusion  of  the  peritoneal  inflammation,  this  time  being, 
according  to  his  views,  between  the  fifth  to  the  seventh,  and  the  eleventh  to  the 
fourteenth  day. " 

Parker's  paper  at  once  provoked  discussion  in  many  quarters,  and  the 
method  recommended  came  into  use  immediately.  This  prompt  response  is  in 
marked  contrast  to  the  lack  of  notice  of  Hancock's  no  less  able  exposition,  and 
we  are  here  tempted  to  inquire  why.  The  reason,  I  think,  lies  in  the  commonly 
observed  fact  that  the  success  of  any  new  departure  in  an  unexplored  field 
must  depend  upon  two  factors:  the  hour  and  the  man.  In  Hancock's  case, 
while  the  man  was  there,  the  hour  had  not  yet  struck:  his  insight  and  sagacity 
were  equal  to  the  opportunity,  but  the  date  was  too  early  and  the  medical 
mind  as  yet  immature.  Parker,  on  the  other  hand,  commanded  every  requisite 
to  success:  the  child  of  a  distinguished  father,  himself  a  man  of  preeminence 
in  the  medical  world,  a  great  teacher,  and  the  foster-father  of  many  of  the  besi 
surgeons  America  has  ever  seen,  he  was  also  fortunate  in  that  his  paper  was 
born  in  a  happy  hour.  During  the  years  that  lay  between  Hancock's  work  and 
his  own,  the  medical  profession  had  been  steadily  acquiring  the  anatomical  and 
pathological  knowledge  necessary  for  many  simultaneous  great  advances  in 
surgery;  all  things  were  in  readiness,  and  a  guarantee  of  safety  alone  was  needed 
to  inaugurate  a  new  era.  The  year  following  Parker's  publication  this  primal 
necessity  was  supplied  in  the  principle  of  antisepsis,  which,  though  discovered 
and  published  in  1863  in  France,  by  Jules  Lemaire,  was  also  independently 


36  HISTORY. 

discovered  and  introduced  into  surgical  practice  by  Sir  Joseph  Lister  in  L868, 
the  year  following  the  appearance  of  Parker's  article.  Then  al  last,  with 
the  advent  of  Lister,  a  host  of  new  conceptions,  heretofore  lying  dormant  under 
tlic  dread  of  working  more  woe  than  weal,  were  quickened  into  the  familiar 
procedures  by  which  we  now,  as  the  weeks  run  their  course,  save  thousands  of 
lives. 

Had  Hancock  lived  twenty  years  later,  his  suggestions  would  not,  in  all 
probability,  have  fallen  upon  sterile  ground.  They  proved  unfruitful,  simply 
because,  though  technically  correct,  their  execution  involved  a  risk  to  life 
which  circumstances  could  then  rarely  justify.  Parker  succeeded  because 
antisepsis  stood  ready  as  his  handmaid  to  step  in  and  reduce  the  risk  to  a 
minimum. 

Evidence  of  the  transformation  taking  place  in  the  entire  surgical  field  he- 
comes  more  and  more  evident  alter  this  date.  Parker's  first  paper,  just  discussed, 
appeared  in  March,  1867;  anil  in  June  of  the  same  year  a  similar  case,  seen  by 
Parker  in  consultation,  and  operated  upon  by  his  advice,  with  recovery,  was 
reported  by  1  'i'.  Burge. 

Leonard  Weber,  in  the  year  1871,  published  an  article  on  "Abscess  <>/ 
the  vermiform  appendix"  which  gives  a  good  description  of  inflammation 
of  the  appendix,  but  the  writer  remarks  that  the  symptoms  are  common  to 
typhlitis  and  perityphlitis  as  well,  showing  no  comprehension  of  the  identity 
of  the  three  conditions.  In  reading  the  literal  ure  of  this  period  we  often  observe 
that  the  immediate  effect  of  discarding  the  theory  that  disease  of  the  appendix 
was  hut  an  extension  of  a  morbid  process  originating  in  the  cecum  was  to 
establish  a  belief  in  the  existence  of  three  morbid  conditions  in  the  iliac  fossa, 
namely,  inflammation  of  the  appendix,  of  the  cecum,  and  of  the  pericecal  tissue. 

W.  T.  Bull,  in  ls7:>,  in  his  inaugural  address  on  "Perityphlitis,"  gave  a 
list  of  all  cases  treated  by  incision  up  to  that  date.  Strange  to  say.  Hancock's 
is  not  included  ;  hut  if  this  is  added,  the  whole  number  of  incisions  (made  before 
fluctuation)  tip  to  this  date  is  nine. 

J.  W.  S.  GoiILAY,  after  the  lapse  of  two  years,  presented  another  such  list, 
including  all  cases  up  to  1875,  the  year  in  which  he  wrote.  I  cite  this  list  as 
it  stands  in  Goulay's  article,  except  that  I  have  prefixed  to  it  the  names  of 
Parker  and  of  Hancock,  which  in  the  original  are  mentioned  in  the  text. 

Hancock:  Lancet,  1848. 

Willard  Parker:  New  York  Med.  Etec,  1S(i7.     (4.) 

Stiegel:  Schmidt's  Jahrbiicher.     (2.) 

1..  Weber:  New  York  Med.  .lour..  1871. 

E.  Krackowizer:  Schmidt's  Jahrbiicher. 

H.  B.  Sands:  New  York  Med.  Jour.,  Aug.,  1S71. 

Charles  Kelsey:  New  York  Med.  Rec,  Oct.  1  and  Dee.  15,  1874.     (2.) 

S.  P..  Ward:  [bid.,  Nov.  2.  1874. 

Samuel  Whitall:  Ibid..  Mav,   1874. 


GOULAY.  37 

Gordon  Buck:  Address  to  New  York  Academy  of  Medicine,  Sept.,  1874. 

J.  P.  P.  White:  Ibid. 

J.  R.  Wood:  Ibid.     (3.) 

J.  C.  Hutchinson:  Persona]  communication.     (2.) 

R.  B.  Bontecou:  Trans.  New  York  State  Med.  Soc,  1873.     (3.) 

C.  A.  Leale:  Personal  communication.     (2.) 

J.  H.  Pouley:  New  York  Med.  Pec,  April  17,  1S75. 

J.  W.  S.  Goulay:  Trans.  New  York  State  Med.  Sue,  1873. 

Goulay 's  list  includes  twenty-eight  cases,  showing  an  increase  of  nineteen 
for  the  two  years  between  the  publication  of  his  article  and  Bull's.  He  remarks : 
"These  are  all  the  cases  treated  by  incision  as  above  described  that  have  come 
to  my  knowledge;  but  it  is  more  than  probable  that  since  1867,  when  attention 
was  recalled  to  the  importance  of  early  incision,  many  surgeons  have  resorted 
to  the  operation,  who  have  not  yet  given  publicity  to  their  experience.  It  is 
hoped,  however,  that  they  will  soon  do  so,  and  aid  in  popularizing  this  most 
valuable  and  life-saving  mode  of  treatment."  A  practical  answer  to  this 
forecast  is  given  by  Noyes,  who  in  1882  records  eighty-four  cases  of  early  incision, 
since  Parker's  in  1867.  If  we  deduct  from  this  number  the  twenty-eight  cases 
by  Goulay,  we  have  fifty-six  for  the  seven  years  between  the  appearance  of  the 
two  articles. 

It  is  of  interest  to  note  here  the  reduction  of  mortality  from  "  perityphlitis" 
after  the  introduction  of  the  Parker  operation.  In  1867  the  death-rate  was  forty- 
seven  per  cent.,  while  in  1SS2,  when  Noyes  wrote,  Parker's  operation  had  been 
in  use  for  fifteen  years  and  the  mortality  was  reduced  as  low  as  fifteen  per  cent. 

Up  to  this  period,  that  is  to  say,  the  early  eighties,  incision  and  the  evacuation 
of  pus  in  the  absence  of  fluctuation  was  the  most  daring  procedure  any  one  had 
as  yet  ventured  to  propose;  but  the  time  was  now  at  hand  when  much  more 
radical  measures  were  about  to  be  adopted. 

I  must  not  omit  mentioning  here  the  names  of  Scandinavian  and  Russian 
surgeons  of  distinction  in  the  decade  1870  and  1880,  Winge,  Selmer.  and 
Holbue,  of  Norway,  Aarestrop,  of  Copenhagen,  and  Anton  Schmidt,  of 
Moscow,  who  all  did  excellent  work  in  elucidating  the  treatment  of  purulent  peri- 
tonitis, thus  contributing  not  a  little  to  the  advancement  of  surgery  in  general 
as  well  as  to  that  of  the  appendix  in  particular. 

Another  factor  furthering  the  progress  of  knowledge  of  diseases  of  the  appen- 
dix, whose  value  we  can  hardly  overestimate,  was  the  constant  exploration  of 
the  abdominal  cavity  by  the  gynecologists  with  such  impunity  that  they  may 
be  said  to  have  paved  the  way  for  the  general  surgeons  who  first  ventured 
to  remove  the  appendix. 

Juiluari).  a  French  gynecologist,  in  1879  gave  good  grounds  for  hope  in 
the  treatment,  even  of  desperate  cases,  by  his  careful  record  of  a  successful 
operation  for  a  case  of  peritonitis  in  a  woman  of  twenty-eight  with  an 
ovarian   tumor.      Twentv-four  hours  before  the    date    fixed   for   its   removal 


38  HISTORY. 

she  was  taken  ill  with  a  peritonitis  lasting  for  seven  days,  at  the  end  of 
which  time  symptoms  of  strangulation  appeared,  when  Juilliard  operated. 
The  cyst  was  removed,  and  the  strangulation  found  due  to  adhesions  gluing 
the  intestine-  together  and  requiring  an  enlargement  of  the  original  incision 
to  set  them  free.  The  operation  was  performed  antiseptically,  and  the  patient 
recovered.  In  the  discussion  following  the  report  of  this  ease,  the  fact  was 
emphasized  that  not  only  was  the  operation  done  during  an  acute  peritonitis, 
but  it  had  been  possible  to  reduce  a  strangulation,  and  make  two  punctures  in 
the  intestine  with  an  aspirator,  and  yet,  despite  these  act-,  at  that  time  un- 
precedented, the  patient  had  made  an  ideal  recovery.  Such  facts  warranted 
the  inference  that  the  abdomen  not  only  could,  but  ought  to  be  opened  more 
frequently;  one  speaker  remarking,  " I'ovariotomie  now  "  montrS  qu'on  pent 
a  peu  pres  impun&menl  ouvrir  In  caviii  peritoneale." 

Herring  Burchard,  of  New  York,  in  the  following  year.  1880,  read  a 
paper  on  "Operative  intei  in  acute  perforative  typhlitis"  before  the  New 

York  Academy  of  Medicine,  based  upon  four  cases  in  hi-  own  practice,  all 
ending  fatally.  He  asks:  "Is  this  disease  necessarily  fatal  ? "  and  replies  to 
his  own  question:  "It  i-  surprising  that  some  definite  plan  of  treatment  has 
not  been,  as  yet,  devised  for  an  affection  the  anatomical  lesions  of  which  are 
of  such  a  nature  as  not  to  preclude  surgical  interference.  \I1  hopes  from  the 
use  of  medicinal  agents  have  been  buried  in  the  uniformly  fatal  termination  of 
the  disease,  and  I  would,  therefore,  suggest  that  by  a  timely  interference  there 
i<  a  reasonable  hope  of  saving  a  certain  proportion  of  lives."  lie  then  adverts 
to  the  numerous  instance-;  of  wounded  intestines  which  have  recovered  notwith- 
standing the  large  openings  made,  and  regards  it  as  singular  that  injuries  of 
such  gravity  could  he  survived  while  minute  perforations  in  the  appendix 
proved  so  fatal.  Burchard  recommends  a  posterior  incision  in  order  to  reach  the 
appendix,  extending  transversely  from  a  point  about  two  inches  in  front  of  the 
anterior  border  of  the  longissimus  dorsi  muscle,  forward  about  six  indies  parallel 
to.  and  just  above,  the  crest  of  the  iliuni.  Through  such  an  opening  the  cecum 
can  he  readily  reached,  the  abdominal  cavity  cleansed,  and  the  edges  of  the 
perforation  stitched  to  the  wound. 

Lawson  Tait.  that  great  pioneer  in  our  art,  writing  a  year  later,  in  1881, 
had  become  so  convinced  of  the  safety  attending  abdominal  section  that  he 
challenged  the  surgical  world  in  these  clarion  note-;  "So  satisfied  have  I  been 
with  the  results  in  these  cases,  that  in  the  next  case  of  peritonitis  to  which 
I  am  called,  of  whatever  sort  it  he.  even  puerperal,  I  shall  advise  and  perform 
(if  allowed)  abdominal  section,  shall  cleanse  out  the  cavity  and  drain  it;  and 
if  the  operation  he  not  deferred  until  the  patient  i-  moribund,  I  believe  this 
treatment  will  prove  eminently  successful.  "  Close  on  the  heels  of  this  prophecy 
followed  the  events  foretold  by  the  seer. 

Xoves.  in  1882.  in  the  article  mentioned,  asks:  "How  shall  we  treat  that 
great  class  of  cases  of  perforation  of  the  appendix  vermiformis  in  which  there 


XOYES.      PENWICK.      MIKULICZ.  39 

is  no  circumscribed  collection  of  pus?"  quotes  Burchard's  suggestion,  and 
notes  a  similar  proposal  by  W.  A.  Byrd  in  1881,  but  concludes  despondently: 
"  I  fail  to  find  any  recorded  cases  in  which  this  procedure  (laparotomy)  has  been 
attempted  with  success.  However  plausible  and  important  this  operation 
really  is,  the  difficulty  of  certainty  of  diagnosis  will  stand  as  an  almost  unsur- 
mountable  obstacle  to  its  adoption.  Medicine  is  useless  in  these  cases,  except 
for  the  production  of  euthanasia,  and  surgery  cannot  even  accomplish  this." 

It  is  a  relief,  after  such  despondency,  to  encounter  the  more  cheerful  outlook 
of  Samuel  Fenwick,  who  says,  in  1884 :  "The  remarkable  success  which  has  of  late 
years  attended  the  operation  of  ovariotomy  encourages  the  belief  that  if  our  diag- 
nosis could  be  made  more  certain  some  of  the  diseases  now  rebellious  to  medicine 
might  be  relieved  by  surgical  treatment,  for  there  can  be  no  doubt  that  many  of 
the  operations  performed  prove  unsuccessful,  not  so  much  from  the  nature  of 
the  malady,  or  from  any  special  liability  of  the  injured  structures  to  secondary 
inflammation,  as  from  the  late  period  at  which  they  are  urn  lertaken.  I  would  first 
invite  your  attention  to  a  rare  disease,  the  occurrence  of  which  has  of  late  years 
attracted  the  attention  of  practitioners,  and  which  often  presents  consider- 
able difficult}'  in  diagnosis,  namely,  inflammation  of  the  vermiform  appendix." 
Discussing  the  method  in  use,  namely,  the  incision  into  the  suppurating  part 
and  the  evacuation  at  the  most  dependent  portion  of  the  swelling,  he  says: 
"Neither  of  these  are  satisfactory,  for,  theoretically,  it  would  seem  to 
be  much  better  if  we  could  cut  down  directly  upon 
the  appendix  as  soon  as  the  diagnosis  was  tolerably 
certain,  tie  it  above  the  seat  of  perforation  and  re- 
move from  its  neighborhood  any  concretion  or  d  e  c  o  m- 
posing  material  that  might  be  the  cause  of  irrita- 
tion.-' 

I  have  emphasized  these  words  because  they  represent  the  conclusion  of 
the  pre-celiotomy  period  in  the  history  of  the  appendix,  when  simple  incision 
and  the  evacuation  of  the  pus  were  recognized  as  the  proper  surgical  treatment. 
The  actual  removal  of  the  appendix  now  became  the  focal  point  of  the  surgical 
world,  and  the  modern  era  of  medical  surgery  was  about  to  begin. 

Professor  .Mikulicz,  of  Krakow,  threw  open  the  door  which  his  predecessors 
had  left  ajar,  in  an  address  on  "Ueber  Laparotomie  bei  Mat/en-  und  Darmper- 
foration  "  in  1884,  to  which  we  are  greatly  indebted. 

"The  therapeutics  of  the  time  demand,"  he  remarks,  "that  perforation  of 
the  stomach  and  intestines  should  be  treated  by  opening  the  abdominal  cavity, 
suturing  the  perforation,  and  restricting  the  inflammation  of  the  peritoneum 
by  thoroughly  washing;  out  the  abdominal  cavity.  These  measures  have  only 
as  yet  been  tried  for  traumatic  perforation,  but  I  am  convinced  that 
the  principle  should  be  as  firmly  established  in  every 
form  of  perforation  as  that  of  a  ligature  for  injury 
to   a   large   b  1  o  o  d-v  essel;   in   both   cases,   its  accomplish- 


40  HISTORY. 

liiont  is  a  v  i  t  a  1  necessity."  fn  a  case  in  his  own  practice  the  patient 
was  taken  suddenly  ill  with  violent  iliac  pains  accompanied  by  vomiting,  and 
obstipation  lasting  three  days.  An  undefined  tumor  was  felt  under  anesthesia, 
in  the  righl  iliac  fossa,  and  the  diagnosis  made  of  either  perityphlitis  or  intestinal 
obstruction  from  invagination.  <  >n  the  fifth  day  the  abdomen  was  opened  by 
an  incision  in  the  linea  alba,  extending  from  the  umbilicus  to  the  pubis,  and 

about  a  litre  of  purulent  bl l-stained  fluid  escaped  ;  the  intestines  were  adherent 

in  many  places,  showing  signs  of  intense  inflammation.  "I  placed  my  hand," 
he  says,  "  in  the  region  of  the  cecum  and  the  ascending  colon,  in  the  expectation 
of  finding  here  the  origin  of  the  supposed  intestinal  obstruction  in  an  ileocolic 
invagination,  but  T  could  find  nothing  except  adhesions  between  loops  of  intes- 
tines, so  that  after  loosening  the  intestines  so  far  as  they  seemed  to  obstruct 
the  circulation,  and  purifying  the  abdominal  cavity  as  far  as  possible  by  means 
of  sponges,  I  closed  the  abdomen."  Immediate  relief  was  experienced,  and  for 
a  short  time  the  patient  improved,  hut  death  occurred  five  days  after  the  opera- 
tion. The  autopsy  showed  a  general  iilnino-purulent  peritonitis  with  extensive 
adhesions,  and  numerous  encapsulated  collections  of  pus.  The  inflammation 
was  must  intense  in  the  region  of  the  colon,  and  the  vermiform  appendix,  which 
was  flexed  on  itself,  was  perforated  with  numerous  small  openings  leading  directly 
into  its  lumen.  Its  mucous  membrane  was  entirely  destroyed.  "This  case," 
Mikulicz  remarks,  "is  of  great  interest  from  an  operative  standpoint.  I  con- 
sidered the  patient's  case  hopeless  when  the  abdominal  cavity  proved  to  be 
full  of  purulent  exudate,  and  1  expected  him  not  to  survive  the  operation  more 
than  a  few  hours.  Therefore,  when  the  theory  of  an  invagination  was  disproved, 
I  made  no  farther  search  for  the  cause  of  the  peritonitis.  To  my  astonishment, 
the  patient  not  only  did  not  become  worse  during  the  next  day  or  two.  but  his 
condition  improved  in  some  small  degree,  no  doubt  on  account  of  the  favorable 
influence  exerted  by  emptying  the  purulent  exudate;  and  the  return  of  the 
symptoms  which  resulted  in  death  was  doubtless  due  to  the  return  of  the  exu- 
date. Had  I  sought  farther  for  the  origin  of  the  exudate,  hail  I  investigated 
the  neighborhood  of  the  cecum  by  sight  as  well  as  by  touch,  the  perforation 
of  the  appendix  could  not  have  escaped  me,  and  I  should  have  excised  it  entirely, 
or  closed  the  opening  into  the  cecum  by  sutures.  And  I  am  convinced  that 
the  peritonitis  would  then  have  subsided,  and  the  patient  would  have  been 
saved."  A  similar  case  fell  into  Mikulicz's  hands  a  few  months  later,  ami  he 
pursued  the  plan  he  here  outlined  of  f  i  a  d  i  n  g  the  p  e  r  f  o  r  a  t  i  0  n  a  n  d 
closing  it  by  sutures,  with  perfect  s  u  c  c  e  s  s.  It  happened 
that  the  perforation  in  thi-  second  case  was  not  situated  in  the  appendix,  but  in 
the  small  intestine.  Mikulicz,  therefore,  although  not  the  firsl  to  operate  upon 
the  appendix,  established  the  propriety  of  such  operations  for  non-traumatic  per- 
forations of  tlii^  organ.  His  conclusions  are:  "  From  the  foregoing  experience, 
scanty  as  it  is,  we  draw  the  conclusion  that  laparotomy  should  be  performed  for 
every  species  of  non-traumatic  perforation  of  the  stomach  or  intestines,  if  it  can 


KBONLBIN.  41 

only  be  clone  early  enough;  if  possible,  before  the  advent  of  peritonitis.  It  is 
most  important  to  understand  the  indications  for  it  in  perforation  of  the  appen- 
dix, as  well  as  in  typhlitis  and  perityphlitis  dependent  on  the  latter;  and  it  is 
just  here  that  we  expect  our  experiences  in  the  future  to  set  the  matter  in  a  new 
light.  In  this  connection  I  cannot  refrain  from  expressing  my  opinion  that 
in  severe  cases  of  typhlitis  and  perityphlitis,  even 
without  perforati  o  n  o  f  t  h  e  a  p  p  e  n  d  i  x,  the  t  h  e  r  a  p  e  u  t  i  c 
treatment  hitherto  e  m  ployed  should  y  i  e  1  d  to  o  p  e  r  a- 
t  i  v  e.  I  do  not  mean  that  every  case  of  obstipation  and  vomiting  accom- 
panied by  swelling  in  the  cecal  region  should  be  treated  by  the  knife,  but  that 
where  there  are  undeniable  appearances  of  abscess  and  purulent  peritonitis 
surgical  principles  should  be  adopted  and  the  products  of  inflammation  removed 

as  early  as  possible I  should  like  to  remark  here  also  that  i  n  any 

peritonitis,  the  original  cause  of  which  is  not  clear, 
the  region  of  the  cecum  should  be  investigated, 
and  a  possible  perforation  of  the  a  p  p  e  n  d  i  x  c  o  n- 
sidered.  Spontaneous  perforation  is  so  extremely  rare  that  it  should 
never  be  taken  for  granted." 

Kroxleix,  of  Germany,  in  the  same  year,  1884,  performed  the  operation 
advised  by  Mikulicz,  for  the  first  time. 

The  patient,  a  boy  of  seventeen,  was  suddenly  attacked  with  violent  pain 
in  the  ileocecal  region,  followed  by  vomiting,  which  assumed  a  fecal  character 
after  twenty-four  hours.  Seen  by  Kronlein  on  the  third  day,  he  was  in  a  state 
of  collapse,  and  an  examination  of  the  abdomen  showed  an  area  painful  even 
on  gentle  pressure  over  Poupart's  ligament  on  the  right  side.  A  diagnosis  was 
made  of  either  perforating  peritonitis  originating  in  the  vermiform  appendix, 
or  of  an  acute  occlusion  of  the  intestine  in  the  right  iliac  fossa.  Operation  was 
performed  immediately  in  a  private  house  and  an  incision  was  made  in  the 
linea  alba  from  the  umbilicus  to  the  pubes;  as  soon  as  the  abdominal  cavity- 
was  opened,  it  was  found  full  of  coils  of  inflamed  intestine  covered  by  fibro- 
serous  exudate.  The  inflammation  was  especially  intense  in  the  ileocecal  region. 
To  cleanse  the  intestines,  they  were  lifted  out  of  the  abdominal  wound,  and 
washed  with  a  lukewarm  solution  of  carbolic  acid  (2.5  per  cent.),  while  the  ab- 
dominal cavity  was  also  washed  out.  The  appendix  was  now  seen  freely  mov- 
able in  the  right  iliac  fossa,  but  much  infiltrated,  ami  with  a  perforation  the  size 
of  a  pea  at  its  middle  portion;  its  edges  were  gangrenous,  and  fecal  concretions  lay 
loose  in  the  perforation.  A  double  ligature  was  placed  at  the  base  of  the  appen- 
dix, with  a  single  ligature  around  the  mesentery,  and  the  appendix  resected  in 
totn,  as  well  as  the  fetid  knotted  omentum,  which  could  not  be  disinfected.  The 
peritoneum  was  carefully  cleansed,  ami  the  abdominal  incision  closed  without 
drainage.  The  patient  recovered  from  the  condition  of  collapse  and  improved 
for  about  twenty-four  hours,  when  the  symptoms  of  collapse  returned  and  death 
took  place  three  days  after  the  operation.     An  autopsy  was  not  permitted. 


42  HISTORY. 


This  operation,  although  performed  in  1884,  was  not  published  until  1886;  in 
spite  of  this  delay  in  appearance,  however,  it  still  remains  the  first  instance  of 
celiotomy,  followed  by  removal  of  the  appendix,  both  as  to  time  of  performance 
and  date  of  publication. 

Charter  Symonds,  an  Englishman,  in  1885  did  what  is  undoubtedly  the 
first  interval  operation  for  appendicitis,  making  a  lateral  incision,  "without 
opening  the  peritoneum,"  and  without  removing  the  appendix.  The  patient, 
a  man  of  twenty-three,  had  had  repeated  attacks  of  inflammation  in  the  right 
iliac  fossa  during  the  six  months  preceding  his  admission  into  Guy's  Hospital,  and 
was  suffering  from  one  of  these  when  admitted.  lie  had  a  small,  hard,  tender 
lump  in  the  right  groin,  and  a  diagnosis  of  inflammation  of  the  appendix  was 
made  by  I  >r.  .Mahomed,  who  stated  it  as  his  belief  that  there  was  an  abscess  with 
a  fecal  concretion,  and  that  the  periodical  occlusion  of  the  communication  with 
the  cecum  determined  the  recurrence  of  pain  and  the  other  symptoms.  Dr. 
.Mahomed  advised  operation  when  the  acute  symptoms  should  have  subsided, 
and  planned  the  manner  of  its  execution.  lie  died,  however,  before  he  could 
act  upon  his  idea.  Mr.  Symonds,  therefore,  performed  the  operation  after  the 
attack,  and  relates  his  experience  as  follows:  "The  incision  used  was  almost 
exactly  similar  with  that  used  in  ligating  the  external  iliac  artery.  The  various 
structures  were  then  divided,  and  as  it  was  particularly  wished  to  avoid  the 
peritoneum,  they  were  at  once  lifted  out  of  place,  when  the  lump  was  plainly 
felt  as  a  hard  round  body.  A  vertical  incision  was  then  made  down  on  to  the 
mass  anil  a  hard  calcareous  body  exposed  ami  removed.  No  pus  at  all  was  seen, 
and  the  cavity  from  which  the  calculus  was  removed  seemed  smooth  and  free 
from  deleterious  material.  The  lining,  which  was  soft  and  purplish,  was  evi- 
dently mucous  membrane,  and  the  tortuous  cord-like  appendix  could  be  dis- 
tinctly  traced,  so  that  there  seemed  no  doubt  that  it  had  been  laid  open.  The 
opening  was  closed  and  a  large  drainage-tube  inserted.  The  peritoneum  was  not 
recognized,  and,  presumably,  not  opened."  The  patient  ultimately  recovered, 
although  troubled  for  some  time  after  by  a  fecal  fistula.  Mr.  Symonds 's  critique 
upon  the  case  is  as  follows:  "I  believe  I  a  in  correct  in  saying 
that  this  is  the  first  case  in  which  a  concretion  or 
calculus  h  a  s  bee  n  r  e  m  o  v  e  d  f  r  o  m  the  a  p  p  e  n  d  i  x  v  e  r  m  i- 
f  o  r  m  i  s.  w  i  t  h  o  u  t  at  the  s  a  m  e  time  o  p  e  n  i  n  g  an  a  b  s  c  e  s  s, 
anil  the  credit  of  what  value  rests  in  the  procedure  must  be  given  to  my  lamented 
friend.  Dr.  Mahomed,  at  whose  suggestion  the  operation  was  undertaken,  and 
who  advocated  the  inguinal  incision  in  opposition  to  that  along  the  linea  semi- 
lunaris proposed  by  myself."  "I  would  suggest,"  he  continues,  "that  some 
cases,  at  least,  might  be  saved  by  earlier  incision,  before.  I  mean,  fluctuation  is 
felt.  This  treatment  has  been  more  especially  employed  by  the  American 
physicians. " 

The  effect  of  Fitz's  article,  which  appeared  in  1886,  the  year  following,  has 
been  noted,  but  I  have  reserved  his  views  regarding  operation  for  statement 


FITZ.       HALL.  43 

at  this  juncture.  Fitz  points  out  that  surgical  interference  should  be  employed 
at  a  much  earlier  date  than  was  the  custom.  Parker  recommended  the  fifth 
day  as  the  earliest,  but  Fitz,  in  a  table  of  sixty  fatal  cases,  shows  that  thirty- 
four  per  cent,  died  during  the  first  five  days.  "It  is  thus 
evident.  "  he  says,  •'  that  the  earliest  date  fixed  by  Dr.  Parker  is  too  late  to  afford 
the  possibility  of  relief  in  more  than  one-fourth  of  all  the  cases.  Hence,  if  the 
indications  for  operating  justify  the  election  of  a  date  as  early  as  the  fifth  da}-, 
they  still  more  justify  the  choice  of  the  third  day.  The  result  has  shown  the 
wisdom  of  the  former  step,  and  the  evidence  here  presented  seems  not  only  to 
warrant,  but  to  demand  the  latter.  It  is  evident  that  the  operation  to  be  per- 
formed is  that  of  opening  the  abdominal  cavity.  It  is  therefore  unnecessary  to 
state  that  an  act  which  twenty  years  ago  might  have  added  to  the  risks  of  the 
patient,  may  at  the  present  time,  when  properly  performed,  be  confidently 
expected  to  reduce  them  materially."  This  article,  like  Parker's  twenty  years 
before,  appeared  at  the  right  moment,  and  with  its  clear  elucidation  of  the 
relations  of  the  appendix  to  various  misunderstood  abdominal  diseases,  gave 
a  great  stimulus  to  more  aggressive  methods  in  abdominal  surgery. 

It  was  but  natural  that  surgeons  in  the  United  States  should  at  once  respond 
to  such  an  appeal,  and  we  actually  find  that  most  of  the  reports  of  extir- 
pations of  the  appendix  in  the  next  few  years  came  from  American  pens.  The 
question  of  priority  involved  in  these  early  cases  has  been  the  occasion  of  much 
logomachy,  and  I  feel  that  I  am  treading  on  uncertain  and  difficult  ground  in 
approaching  it:  I  can  only  declare  that  I  have  been  at  pains  to  ascertain  the 
exact  details  in  every  case  calling  for  individual  mention. 

R.  J.  Hall,  of  New  York,  performed  the  first  operation  on  the  appendix  in  the 
United  States,  which  is  the  third  on  record,  in  May,  1SS6,  and  published  it  in  the 
following  month  in  the  New  York  Medical  Journal.  The  patient,  a  boy  of  seven- 
teen, had  had  a  reducible  inguinal  hernia  since  childhood.  Two  weeks  before  his 
admission  to  the  Roosevelt  Hospital  he  began  to  suffer  from  obstipation,  and  for 
the  entire  period  had  no  passage  from  the  bowels.  Three  days  before  admission 
the  hernia  became  irreducible,  and  since  that  time  he  had  vomited  persistently 
and  was  apparently  in  collapse.  There  was  constant  severe  pain  and  tender- 
ness over  the  whole  rather  retracted  abdomen,  and  the  hernial  sac  was  swollen, 
red,  and  intensely  painful.  The  right  scrotal  and  inguinal  region  was  occupied 
by  a  pear-shaped  swelling  about  eight  inches  long,  about  the  size  of  two  fists 
at  its  lower  end;  the  skin  over  the  sac  was  congested  and  semi-fluctuating, 
but  not  tense  nor  tympanitic.  A  probable  diagnosis  of  strangulated  hernia 
was  made,  and  an  operation  performed  at  once;  the  incision,  about  three-fourths 
of  an  inch  long,  extended  down  to  the  neck  of  the  hernial  sac,  which  was  opened, 
when  there  escaped  from  the  peritoneal  cavity  a  pint  of  fetid  sero-pus.  Behind  the 
sac  lay  the  swollen  and  edematous  spermatic  cord,  while  just  outside  the  external 
ring  on  the  posterior  wall  was  found  a  solid,  cylindrical  mass  covered  with  a 
greenish,  diphtheritic  exudate.     The  tunica  vaginalis  was  moderately  distended 


44  HISTORY. 

with  fluid  and  at  the  most  dependent  part  of  the  scrotum  was  whal  appeared  to 
be  a  normal  testicle.  Closer  examination  showed  that  this  was  the  vermiform 
appendix,  curled  upon  itself  and  so  thickened  near  its  cecal  attachment  a<  to 
resemble  a  solid  tumor  about  the  size  of  a  testicle;  near  its  base  there  was  a 
small  oval  perforation.  The  appendix  was  ligated  above  this  opening  with 
Catgut,  freed  In  in  i  its  adhesions,  ami  removed.  The  stump  was  disinfected  with 
a  strong  bichloride  solution  il  :1000),  hut  not  sutured.  The  original  incision 
was  then  prolonged  upward  about  three  inches,  and  the  hand  with  the  forearm 
inserted,  so  as  to  explore  the  abdominal  cavity  thoroughly.  The  fresh  adhesions 
were  broken  up.  a  number  of  large  pus  cavities  emptied,  and  a  large  amount 
of  sero-pus  scooped  out  of  the  true  pelvis.  After  cleansing  the  peritoneum  a 
rubber  drain  eight  inches  long  was  inserted.  The  patient's  condition  at  the  end 
of  the  operation  was  very  bail,  but  he  began  to  improve  at  once,  and  made  an 
excellent  recovery.  Hall  remarks:  "While  laparotomy  for  suppurative  peri- 
tonitis has  now  been  successfully  performed  so  often  that  single  cases  scarcely 
attract  attention,  the  number  of  successful  cases  done  for  perforation  is  still 
extremely  small.  In  a  somewhat  hasty  search.  I  have  been  unable 
to  find  any  case  of  perforative  peritonitis  clue  to 
u  1  c  er  a  t  i  o  n  o  f  t  h  e  v  e  r  m  i  f  or  in  a  p  pe  n  d  i  x,  s  uccessfull  y 
treated  by  lap  a  r  o  t  o  in  y  and  res  e  C  t  i  0  n  o  f  t  h  e  a  p  p  e  n- 
d  i  x  itself."  This  claim,  if  the  qualifications  are  borne  in  mind,  seems  to 
be  fully  justified,  for  Kronlein's  case,  it  will  be  remembered,  did  not  recover,  and 
that  of  Symonds  was  not  performed  for  perforative  peritonitis,  nor  did  lie  resect 
the  appendix.  Hall's  operation  was  undertaken  for  the  relief  of  an  incarcerated 
strangulated  hernia,  and  the  lesion  of  the  appendix  was  discovered  incidentally. 
so  that  while  the  first  to  succeed  in  extirpating  a  perforated  appendix,  it  yet 
remains  for  us  to  discover  who  executed  with  intention  the  first  successful  opera- 
tion for  disease  in  that  organ. 

To  Thomas  (1.  Morton,  of  Philadelphia,  belongs  the  credit  of  the  first  suc- 
cessful  operation  for  the  removal  of  the  appendix,  deliberately  undertaken  with 
an  alternative  diagnosis  of  disease  in  the  organ.  The  date  was  April  27,  1887,  and 
the  report  of  the  case  is  in  the  Transactions  of  (lie  CoUcge  of  Surgeons  of  Phil- 
adelphia for  the  same  year.  The  patient,  a  man  of  twenty-six,  had  been  subject 
to  repeated  attacks  of  abdominal  pain  during  the  four  years  previous  to  the 
illness  in  question.  lie  consulted  Dr.  Frank  Woodbury,  of  Philadelphia,  on 
April  20th,  complaining  of  a  cold.  The  previous  day,  while  driving,  he  had 
had  a  violent  attack  of  abdominal  pain  lasting  some  hours,  by  which  he  was 
still  prostrated  when  he  appeared  in  Dr.  'Woodbury's  office.  During  the  next 
few  days  lie  grew  steadily  worse,  and  the  pain  in  the  abdomen  increased,  accom- 
panied by  nausea  and  vomiting,  while  the  bowels  were  somewhat  relaxed. 
On  examining  the  abdomen,  a  point  of  greatest  tenderness  was  found  midway 
between  the  umbilicus  and  the  middle  of  Poupart's  ligament,  where  a  resistant 
mass  which  did  not  cause  severe  pain  could  be  made  out   on  pressure.      A 


MORTON.      TREVES.  !•"> 

diagnosis  of  probable  perityphlitis  was  made  by  Dr.  Woodbury  and  Dr.  J.  C. 
Wilson,  and  Dr.  Morton  was  summoned  in  consultation  to  consider  the  question 
of  operation.  By  bis  advice,  this  was  immediately  undertaken,  although  the 
patient  was  extremely  ill.  Dr.  Morton  made  an  incision  directly  over  the 
swelling,  and  when  the  deep  muscles  were  found  infiltrated  with  pas,  this  was 
extended  until  it  was  ten  inches  in  length.  The  peritoneum  was  opened,  and 
a  free  flow  of  pus  with  a  fecal  odor  followed.  In  the  abscess  cavity,  near  the 
appendix,  was  a  concretion  the  size  of  a  cherry-stone.  The  appendix  itself  was 
greatly  swollen  and  had  a  perforating  ulcer  extending  around  its  circumference. 
A  silk  ligature  was  applied  close  to  the  cecum,  and  another  at  the  terminal  por- 
tion of  the  appendix;  the  intervening  portion,  which  comprised  almost  the  whole 
of  the  organ,  was  then  removed,  together  with  a  large  piece  of  omentum  that 
projected  into  the  abscess  cavity,  whose  walls  were  curetted  and  douched  with 
hot  water  at  110°  F.  The  peritoneal  cavity  was  also  douched  until  cleared  of 
pus,  and  a  drainage-tube  carried  into  the  lowest  part  of  the  pelvic  basin.  The 
patient  began  to  improve  at  once  and  made  a  rapid  recover}-. 

I  have  abstracted  this  account  from  the  original  publication,  supplementing 
it  with  details  furnished  me  in  a  personal  communication  by  Dr.  Woodbury, 
from  whom  I  also  learn  that  the  patient  is  still  living,  engaged  in  active  and 
successful  business. 

I  turn  here  for  a  moment  to  the  question  of  priority  raised  some  five  years 
later  by  Sir  Frederick  Treves.  The  Philadelphia  Medical  News  of  August  6, 
1892,  contained  an  editorial  giving  Morton  the  credit  of  first  seeking  out  and 
removing  the  ulcerated  appendix,  and  suggesting  that  the  procedure  might  well 
be  called  "Morton's  operation.''  This  attracted  the  notice  of  Sir  Frederick 
Treves,  and  elicited  the  following  letter,  in  the  issue  for  November  5,  1892: 

"I  have  just  read  with  interest  a  leading  article  in  the  Medical  News  for 
August  6  on  the  matter  of  operative  treatment  of  the  vermiform  appendix. 
The  fact  that  I  live  in  a  remote  island,  and  further  that  a  holiday  of  two  months 
has  taken  me  away  from  the  haunts  of  books,  must  explain  this  tardy  allusion 
to  that  paper. 

"The  article  discusses  the  origin  of  the  operation  for  removing  the  vermiform 
appendix,  and  it  is  stated  that  to  Dr.  Thomas  (I.  Morton  belongs  the  credit 
of  first  devising  this  procedure:  the  suggestion  is  also  made  that  the  operation 
should  be  called  'Morton's  operation.'  and  it  is  asserted  that  Morton's  opera- 
tion embodies  one  of  the  most  important  and  radical  advances  of  modern 
surgery.  Dr.  Morton  thus  becomes  the  founder  of  what  will,  I  suppose,  be  known 
as  'Appendiceal  Surgery,'  should  the  present  love  for  ridiculous  terms  survive. 

"I  gather  that  Dr.  Morton's  first  operation  was  performed  in  1888,  and  was 
reported  in  the  Philadelphia  County  Society's  Transactions  for  that  year.  The 
nature  of  the  transaction   is   not  stated.     Who  first  excised  the  appendix  some 

musty  and  forgotten  tome  will  no  doubt  reveal  in  course  of  time In 

1S86  a  patient  with  relapsing  typhlitis  came  under  my  care  at  the  London 
Hospital,  and  after  due  consideration.  I  proposed  to  'deliberately  seek  for  and 
remove  his  appendix.'     I  operated  on  him  during  a  period  of  apparent  health,  on 


46  HISTORY. 

February  16,  1887,  and  was  able  to  correct  the  distortion  of  the  appendix  without 
removing  it.     lie  made  a  perfect  recovery.    On  September  19,  1887,  1  brought 

the  matter  before  the  Royal  .Medical  and  Chirurgical  Society.  The  paper  was 
read  in  February,  1888.  1  advised  the  treatment  of  selected  cases  of  relapsing 
typhlitis  by  the  deliberate  removal  of  the  offending  appendix  during  a  quiescent 
period.    The  proposal  was  not   well   received.     In  due  course,  however,  an 

exuberant  reaction  took  place,  and  of  late  appendices  have  been  removed  with 
a  needless  ami  illogical  recklessness  which  has  brought  this  little  branch  of  sur- 
gery  into  well-merited  disrepute. 

"  Discussions  on  questions  of  priority  constitute  the  most  pitiable  and  petty 
items  in  the  literature  of  medicine.  The  object  of  this  letter  is  merely  to  bring 
up  from  oblivion  an  unpretending  paper  which  lies  buried  in  the  annals  of 
an  ancient  society. 

"  Believe  me  to  remain,  yours  faithfully, 

"Frederick  Treves." 

As  a  matter  of  fact,  neither  Morton  nor  Treves  is  entitled  to  the  distinction 
of  first  removing  the  appendix,  since  Kronlein,  as  I  have  shown,  made  the 
diagnosis  and  performed  the  operation  in  February,  1884,  and  published  the 
account  in  1886.  Morton's  operation  was  performed  on  April  19,  1887,  and 
published  in  the  Transactions  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia  for  1887.  Treves 's  operation,  "the  correction  of  a  distortion  of 
tin1  appendix,"  was  performed  on  February  lb,  1887,  but  not  published  until 
the  year  1SSS,  in  the  Transactions  of  the  Medico-Chirurgical  Society.  Any 
claim  to  priority  in  medicine  or  surgery  always  rests  by  the  consent  of  the  pro- 
fession not  upon  date  of  performance,  but  upon  date  of  publication.  Reflec- 
tion will  only  confirm  this  dictum  by  showing  that  the  printed  word  is,  after 
all,  the  only  possible  arbiter  which  can  be  generally  appealed  to  and  accepted 
when  disputes  arise.  Moreover,  in  the  particular  case  in  hand,  the  operations 
done,  although  having  the  same  organ  in  view,  were  essentially  different — one 
was  purely  orthopedic  and  the  other  exsective;  it  is  the  difference  between  a 
plastic  operation  upon  a  limb  and  an  amputation;  therefore,  in  view  of  this 
fact  alone,  no  conflicting  claims  as  to  priority  can  be  raised. 

II.  B.  SANDS,  of  New  York,  operated  for  disease  of  the  appendix,  after 
making  a  definite  diagnosis,  on  December  30,  1887,  and  published  the  case  on 
June  lb,  1NSS.  Sands  had  for  some  time  taught  the  principles  he  here  put  into 
practice,  and  it  was  his  conviction  that  the  operation  he  reported  was  the  first 
successful  one  of  its  kind,  since  Halls  case,  as  he  truly  observes,  was  accidental 
and  not  preconsidered;  of  Morton's  case,  apparently,  he  had  not  heard. 

Sands's  patient  was  a  young  man,  ill  for  some  days  with  pain  in  the 
lower  abdomen,  accompanied  by  vomiting  in  the  first  stapes.  There  were 
exquisite  tenderness  over  the  right  iliac  fossa  and  tympanites,  but  no  tumor. 
Dr.  Sands  made  a  diagnosis  of  acute  septic  peritonitis  caused  by  a  per- 
foration of  the  appendix,  ami  advised  immediate  operation.  Dr.  S.  Baruch, 
who  saw  the  case,  was  in  favor  of  incising  above  Poupart's  ligament,  as  for 


SANDS.  47 

perityphlitis  abscess,  to  try  to  evacuate  the  pus  without  opening  the  peri- 
toneum. Sands,  however,  confident  that  the  patient  had  an  acute  septic 
peritonitis,  and  that  opening  the  abdomen  alone  could  effect  a  cure,  pre- 
ferred a  vertical  incision  over  the  caput  coli,  giving  free  access  to  the 
diseased  parts  and  allowing  thorough  work.  At  the  operation,  forty-eight 
hours  after  onset  of  the  attack,  a  vertical  incision  four  inches  long  was 
made,  beginning  at  a  point  about  half  an  inch  above  the  middle  of  Poupart's 
ligament  and  ending  about  the  same  distance  below  the  level  of  the  umbilicus. 
This  was  afterward  lengthened  three-fourths  of  an  inch  below.  The  parietal 
and  adjacent  visceral  peritoneum  was  found  covered  with  pus  and  recent  lymph. 
In  the  iliac  fossa,  a  fecal  concretion  lay  free  in  the  peritoneum  below  the  cecum, 
and  a  similar  one  had  partly  escaped  from  the  opening  at  the  base  of  the  appen- 
dix. The  margins  of  this  opening  were  slightly  trimmed  with  scissors  and 
brought  together  with  three  silk  sutures.  The  diseased  parts  were  then  irrigated 
with  warm  water,  and  syringed  with  half  a  pint  of  a  solution  of  warm  bichloride 
of  mercury  (1  :1000).  The  upper  part  of  the  abdominal  wound  was  closed  and 
the  lower  part  left  open  and  packed  with  iodoform  gauze.  Immediate  improve- 
ment followed  and  the  patient  recovered.  Sands  says:  "I  diagnos- 
ticated the  case  as  one  of  acute  septic  peritonitis 
caused  by  perforation  of  the  v  e  r  m  i  f  o  r  m  a  p  p  e  n  d  i  x, 
a  n  d  a  d  vise  d  a  n  i  m  m  e  d  i  a  t  e  r  e  s  o  r  t  to  1  a  p  a  r  o  t  o  m  y.  " 
and  his  estimate  of  his  accomplishment  is  thus  briefly  expressed:  "I  am 
acquainted  with  no  case  like  mine  in  which  a  perforative  peritonitis,  due  to 
disease  of  the  appendix,  has  been  diagnosticated,  and  treated  by  laparotomy 
with  a  favorable  result.  " 

Sands 's  article,  one  of  the  best  on  the  subject,  deserves  careful  consideration 
from  the  medical  historian.  Dr.  T.  W.  Harvey,  of  Orange,  New  Jersey,  an  early 
student  of  Dr.  Sands,  informs  me  that  he  inculcated  the  surgical  treatment 
of  disease  of  the  appendix  for  some  time  before  the  appearance  of  this  paper. 

We  have  now  traced  the  history  of  our  subject  through  the  successive  stages 
of  its  evolution,  from  the  first  discovery  of  a  lesion  in  1759  down  to  the  time  of 
Pitz  in  18S6,  who  secured  recognition  for  its  diseases  as  a  distinct  class  by 
themselves,  banishing  the  older  misleading  terms  typhlitis  and  perityphlitis. 
We  have  furthermore  witnessed  the  earliest  efforts  of  the  surgeon,  at  first  timidly 
opening  a  few  abscesses  (the  classical  procedure)  ami  then  gradually  growing 
hold  enough  to  take  the  important  step  of  making  the  incision  before  the 
detection  of  fluctuation  (Hancock,  Willard  Parker).  We  then  found  a  few  sur- 
geons, endowed  with  a  courage  born  of  the  newly  inaugurated  antiseptic  rigvntt . 
venturing  to  open  the  peritoneum  and  to  straighten  out  a  kink  (Treves),  or  to 
trim  off  the  edges  of  a  fistula  in  the  appendix  (Sands),  and,  at  last,  to  remove 
the  entire  organ  (Kronlein,  Morton.  Sands). 

It  now  remains  to  note  briefly  the  growing  boldness  of  surgeons  the  world 
over, but  especiallyin  America,  in  opening  the  abdomen  and  removing  the  diseased 


48  HISTORY. 

appendix,  tracing  at  the  same  time,  in  brief  outline,  the  development  of  the 
special  technic  of  the  new  operation.  Upon  the  technic,  however,  I  shall  not 
dwell  at  length,  since  it  deals  with  the  most  modern  phase  of  the  subject  and 
would  involve  repetition  further  on  (see  Chapter  XXV). 

Doubl  dissipated,  and  the  flood-gates  once  thrown  open,  the  healing  waters 
swept  in  like  a  torrent,  carrying  the  beneficent  influences  from  land  to  land,  at 
first  through  the  greater  centres  of  learning,  ami  then  spreading  more  slowly 
out  even  to  the  remotes)  hamlets,  until  to-day  we  may  almost  say  that  no  other 

surgical  affection  is  so  well  underst 1  nor  so  well  treated  as  this,  the  bane  and 

the  opprobrium  of  the  profession  but  a  generation  ago.  In  the  United  States, 
which  holds  a  leading  position  in  the  prompt  recognition  of  the  exact  nature  of 
this  one-time  obscure  malady,  as  well  as  in  the  adoption  of  the  aggressive 
therapeutic  regime  necessary  lor  its  relief,  we  look  hack  upon  such  a  galaxy  of 
names  as  Senn,  Weir,  McBurney,  Worcester,  Marcy,  Fowler,  Mynter,  Richard- 
son, and  many  others  who  deserve  mention,  and  would  receive  it  in  a  more 

extended  work. 

The  farther  evolution  of  the  subject  consists  in  the  development  of  technic. 
from  the  crude  simple  ligation  and  amputation  to  the  various  highly  specialized 
and  often  purely  individual  procedures  now  in  use.  One  of  the  first  steps  in 
the  advance  was  the  sterilization  of  the  stump  of  the  amputated  appendix,  and 
its  protection  with  a  little  cuff  of  peritoneum  left  for  the  purpose;  then  it  was 
ligated  and  depressed  into  the  cecum,  while  the  adjacent  surfaces  of  the  cecum 
were  drawn  over  it  and  stitched;  then  came  the  amputation  flush  with  the 
cecum  with  the  suture  of  the  opened  bowel :  next  the  inversion  of  the  stump,  or 
even  of  the  entire  unopened  appendix;  and,  lastly,  we  find  the  cautery  or  the 
cautery  clamp  employed  to  sterilize  and  seal  the  stump  before  burying  it  in  the 
cecum. 

The  first  step  in  the  improvement  of  the  technic  was  suggested  by  Treves 
(Med.  ami  Chir.  Trans.,  Lond.,  Inns.  p.  17_>).  as  follows:  "In  the  majority  of 
cases  it  would  probably  be  wiser  to  remove  the  appendix.  If  this  is  done,  as 
much  care  must  be  taken  to  close  the  divided  end  of  the  tube  as  would  be  taken 
to  close  a  hole  in  the  small  intestine.  A  mere  ligature  would  not  suffice.  Two 
sutures  would  bring  the  mucous  membrane  together,  and  the  peritoneum  should 
be  adjusted  over  this  line  of  union  by  several  points  of  Lembert's  suture.'' 
Treves  was  shortly  after  able  to  put  his  method  into  practice  (Lancet,  1889, 
vol.  i.  ]).  267).  "The  appendix,"  he  says,  "was  clamped  close  to  the  cecum, 
and  divided  about  half  an  inch  from  that  intestine.  It  should  not  be  secured 
by  a  simple  ligature.  The  mucous  membrane  was  united  by  a  number  of  very 
fine  sutures,  then  the  divided  walls  of  the  process  were  brought  together  by  a 
second  row  of  sutures.  It  is  practically  impossible  to  bring  the  serous  coats 
together. " 

X.  SENN,  in  the  same  year,  recommended  and  employed  the  same  improve- 
ment in  technic  for  the  first  time  in  the  United  States,  where  he  affirms  that: 


SEXX.       McBURXEY.  49 

"It  is  of  the  greatest  practical  importance  to  recognize  the  exact  condition  in 
time,  and  to  anticipate  the  dangerous  and  only  too  often  fatal  complication 
by  removing  permanently  the  source  of  danger,  which  can  he  done  at  this  time 
with  comparative  ease  and  almost  perfect  safety  by  the  extirpation  of  the 
appendix."  With  his  well-known  surgical  insight,  he  adds:  "The  appendix 
was  ligated  near  the  cecum  with  a  silk  ligature,  and  amputated  aboul  a  quarter 
of  an  inch  below  the  point  of  ligation.  The  lumen  of  the  appendix  was  quite 
small,  hut  as  it  was  more  than  probable  that  it  communicated  with  the  cecum, 
I  deemed  it  necessary  to  prevent  the  possibility  of  a  subsequent  perforation  from 
cutting  through  of  the  ligature  by  covering  the  stump  with  peritoneum.  The 
stump  was  disinfected,  dusted  with  iodoform,  and  buried  by  stitching  the  peri- 
toneum from  each  side  over  it  by  a  number  of  stitches  of  the  continued  suture. 
The  cecum  was  now  returned,  ami  the  wound  closed  by  suturing  the  peritoneum 
with  catgut,  while  the  external  sutures  of  silk  were  passed  down  to.  but  not 
through,  the  peritoneum."'  He  follows  this  statement  with  an  excellent 
exposition  of  the  reasons  for  such  an  accurate  closure  of  the  stump,  the  first 
definite,  decided,  and  clearly  reasoned  statement  upon  this  most  important  head. 
Then  with  the  confidence  begotten  of  such  a  perfected  technic,  he  justly  adds: 
"Drainage  in  such  cases  is  unnecessary,  and  should 
be    dispensed    with."' 

C.  McBurney,  in  1889,  deals  with  the  same  subject  in  an  article  which  must 
ever  deserve  to  be  ranked  as  one  of  the  classics  in  the  surgical  history  of  America. 
So  admirable  and  so  clear  are  his  views  as  to  the  proper  surgical  treatment  of 
appendicitis  that  the  experience  of  fourteen  years  has  not  brought  any  radical 
or  important  changes  in  his  methods.  The  value  of  the  memoir  is  such  that 
to  do  it  justice  I  must  quote  somewhat  fully.  After  a  just  tribute  to  the  menu  iry 
of  Sands,  whom  McBurney  had  assisted  "in  a  number  of  successful  operations 
for  the  removal  of  the  appendix  at  an  early  stage  of  the  disease."  he  asks: 
''How  many  cases  of  localized  peritonitis  or  perityphlitis  arise  from  impaction 
of  feces  in  the  cecum?  ....  Is  there  a  single  observation  brought  from 
the  dead-house  or  from  the  operating  table  to  support  this  idea?"  He  then 
emphatically  declares  that  a  peritonitis  localized  in  the  neighborhood  of  the 
cecum  "may  with  rare  exceptions  be  attributed  to  an  inflammation  of  the 

vermiform  appendix  in  some  one  of  its  numerous  stages I  must, 

therefore,  prefer  to  use  the  term  inflammation  of  the  appendix  or  appendicitis, 
and  give  up,  once  and  for  all,  the  terms  perityphlitis,  paratyphlitis,  and  extra- 
peritoneal abscess,  as  misleading  and  not  valuable  except  in  explanation  of 
secondary  pathological  lesions." 

McBurney  then  demonstrates,  in  full  harmony  with  an  admirable  paper 
by  Weir  in  the  same  year,  that  abscesses  formed  in  the  appendix  around  the 
cecum  are  always  primarily  extraperitoneal:  he  says:  "The  peritoneum  may 
be  pushed  back  and  the  abscess  incised  deep  in  the  iliac  fossa  by  a  roundabout 
and  unsurgical  method,  but  when  incised  the  peritoneum  will  be  cut."  Weir 
4 


50  HISTORY. 

had  already  shown  this  same  fact  in  his  analysis  of  100  autopsies,  in  not  one  of 
which  did  the  abscess  originate  in  the  extraperitoneal  tissue. 

In  the  early  operations  for  which  McBurney  was  entering  so  earnest  a  plea. 
he  declares  that  he  had  "found  a  condition  of  the  mucous  membrane  in  its 
surroundings,  varying  from  a  mild  catarrh  of  the  mucous  membrane,  accom- 
panied by  infiltration  and  thickening  of  the  submucous  and  other  tissues,  to 
the  state  of  complete  gangrene  of  the  surrounding  organs." 

He  further  states  that  "the  pathological  condition  of  the  appendix  as  com- 
pared with  the  symptoms  in  my  own  cases  most  positively  show  that  one  can- 
not with  accuracy  determine  from  the  symptoms  the  extent  and  severity  of  the 
disease."  Any  advance  in  knowledge  must  he  by  early  operations,  for  "by 
autopsies  we  cannot  learn  very  much  more  in  this  direction,  if  we  may  judge 
by  the  length  of  time  it  required  to  learn  the  important  fact  that  abscesses 
originating  in  the  appendix  are  almost  invariably  intraperitoneal."  He 
in  lies  the  varying  value  of  the  symptom  pain,  citing  "  one  patient  who  died  on 
the  third  day  from  violeni  septic  peritonitis  from  perf oration^ but  complained 
of  comparatively  little  pain  even  when  the  iliac  fossa  was  firmly  compressed." 

As  to  the  location  of  the  pain  as  a  significant  factor  in  making  a  diagnosis 
of  appendicitis,  the  value  of  the  "McBurney  point"  is  now  so  universally 
known  thai  it  is  most  interesting  to  read  the  first  statements  of  the  author 
relative  to  this  matter:  "The  exact  locality  of  the  greatest  sensitiveness  to 
pressure  had  seemed  to  me  to  he  usually  one  of  importance.  Whatever  may 
he  the  position  of  the  healthy  appendices  found  in  the  dead-house — ami  I  am 
well  aware  that  its  position  when  inflamed  varies  greatly — I  have  found  in  all 
of  my  operation-;  that  it  lay,  either  thickened,  shortened,  or  adherent,  very  close 
to  its  point  of  attachment  to  the  cecum.  This,  of  course,  must,  in  early  stages 
of  the  disease,  determine  the  seat  of  greatest  pain  on  pressure.  And  I  believe 
that  in  every  case  the  seat  of  greatest  pain,  determined  by  the  pressure  of  one 
finger,  has  been  very  exactly  between  an  inch  and  a  half  and  two  inches  from 
the  anterior  spinous  process  of  the  ilium  on  a  straight  line  drawn  from  that 
process  to  the  umbilicus.  This  may  appear  to  he  an  affectation  of  accuracy, 
but,  so  far  as  my  experience  goes,  the  observation  is  correct." 

In  urging  an  early  operation,  he  says:  "The  truth  is  that,  in  the  early 
stage,  no  accurate  diagnosis  can  be  made  as  to  whether  the  appendix  is  per- 
forated or  not.  excepting  in  those  cases  where  comparatively  mild  symptoms 
suddenly  become  much  aggravated,  when  perforation  or  the  rupture  of  an 
abscess  may  be  inferred.  "     "There  is  no  reason  to  think,  however,  that  diagnosis 

from  symptoms  alone  will  ever  reach  that  perfection I  hope  that 

I  may  never  again  go  every  day  to  visit  a  threatening  case,  waiting  bashfully 
for  the  authority  of  a  clearly  defined  peritonitis  before  I  dare  take  action.-' 
The  conclusion  of  the  whole  matter  is  "if  it  can  be  shown  by  future  experience 
with  improved  methods  of  operation,  and  with  more  perfect  antiseptic  precau- 
tions, that  the  exploratory  incision  for  inspection  of  the  diseased  appendix  is 


WORCESTER.  51 

much  more  free  from  danger  than  the  expectant  treatment,  then  there  could 
be  but  one  answer  to  the  question:  What  is  the  best  treatment?" 

In  the  course  of  this  article,  McBurney  relates  the  case  of  a  young  lady  who 

had  no  less  than  twelve  attacks  of  perityphlitis  within  a  year,  where  "the 
operation  was  done  during  a  period  of  complete  health,  and  after  careful  con- 
sideration, to  prevent  recurrence."  He  also  adds,  in  the  midst  of  a  series  of 
other  cases,  the  description  of  one  which  he  says  "is,  I  believe,  t  he  first 
r e  c  o  r  d  e  d  c  a  s  e  w  h  e  r  e  a  n  a  c utel y  i  n f  1  a m e d  appendix 
has    been   removed    full    of    ]  >  u  s. " 

His  method  of  removal  was  to  tie  off  the  appendix  with  silk  or  catgut  and 
to  cut  it  away;  he  then  carefully  disinfected  the  stump,  scraping  its  interior, 
and  applying  a  1:1000  bichloride  solution  and  rubbing  in  iodoform.  In  a 
bad  case  he  used  the  fine  point  of  a  cautery  to  disinfect  the  stump.  He  thought 
it  was  unnecessary  to  sew  the  peritoneum  over  the  stump),  and  concluded  the 
operation  by  inserting  a  drainage-tube  into  the  wound. 

A.  Worcester,  of  Waltham,  Mass.,  in  1892  began  a  series  of  admirably 
clear  presentations  of  our  subject  which  must  have  exercised  a  decided  in- 
fluence on  contemporary  surgical  thought. 

He  begins  his  writing  with  the  declaration  that  "there  is  only  one  logical 
treatment  of  the  disease,  namely,  the  excision  of  the  diseased  organ  as  soon 
as  the  diagnosis  is  made,"  and  he  adds  that  he  is  "too  timid  to 
take  the  responsibility  of  the  risk  that  there  a  1  w  a  y  s 
is  in  delaying  to  evacuate  an  internal  abscess,  and 
a  cake  in  the  right  iliac  fossa,  tender  to  pressure,  in 
a  patient  even  slightly  feverish,  in  cans  a  n  a  b  s  c  e  s  s." 
When,  on  one  occasion,  an  operation  was  delayed  by  the  family  of  the  patient, 
he  declares:  "In  a  similar  case,  I  should  not  now  consent  to  share  with  the 
family  the  responsibility  of  delay." 

In  conclusion,  Worcester  gives  us  the  following  summary  expressed  in  the 
language  of  emphatic  conviction:  "  (1)  Appendicitis  is  an  inflammation  of  a 
useless  organ,  dangerously  situated.  (2)  At  the  beginning  of  an  attack  it  is 
not  possible  to  determine  whether  it  will  prove  of  the  harmless  or  of  the  dangerous 
kind.  (3)  The  diagnosis  is  easy  in  comparison  with  the  task  of  diagnosticating 
the  seat  of  any  acute  inflammation.  (4)  At  the  beginning  of  an  attack,  the 
excision  of  the  appendix  is  an  easy  and  a  perfectly  safe  operation.  (5)  If 
so  treated,  all  complications  and  all  subsequent  attacks  are  avoided.  (6)  In 
view  of  the  results  already  obtained  by  following  this  treatment,  no  other 
treatment  is  worthy  of  consideration." 

G.  R.  Fowxer,  in  1S94,  gave  a  clear  illustrated  description  of  the  method 
of  burying  the  stump  of  the  appendix  in  the  cecum. 

Dawbarx,  in  180.").  described  the  complete  inversion  of  the  amputated 
appendix  into  the  cecum. 

Edebohls,  in   1895,  adopted  the  plan  of  inverting  the  entire   unopened 


o_'  HISTORY. 

appendix  into  the  bowel,  closing  the  dimpled  orifice  at  the  base  in  the  cecum, 
and  leaving  the  inverted  organ  to  slough  off  and  pass  oul  by  the  rectum. 

.1.  B.  Dbaver,  in  1897,  amputated  the  entire  unopened  appendix,  cutting 
it  off  Bush  with  the  cecum,  and  then  suturing  the  wound  as  any  other  in  the 
intestine. 

Skene,  in  1898,  introduced  the  crushing  electro-cautery  forceps. 

Following  Porter,  Cabot,  and  Marcy,  of  Boston,  who  were  active  in  the 
propaganda  of  the  new  idea  that  had  come  to  the  surgical  world,  came  one 
of  its  greatesl  exponents,  Maurice  II.  Richardson,  who  in  1898  was  able 
with  ( i.  \V.  Brewster  to  present  as  many  as  151  cases  operated  upon  "in  the 
interval"  between  the  dates  August,  L894,  and  February,  1898,  without  a  single 
death,  in  an  article  "Appendicitis;  r  e  in  a  rks  base  d  u  p  o  n  a 
personal  experience  of  7  •">  7  eases;  including  1  5  1 
consecutive  eases  operated   upon  'in   the  interval.'" 

In  Great  Britain  the  names  of  Dl  CKWORTH,  of  LoCKWOOD,  and  of  Hawkins 
deserve  mention,  together  with  that  of  Treves,  as  writers  who  have  contributed 
to  our  knowledge  of  the  appendix  in  health  and  disease. 

France  claims  such  eminent  authorities  as  Roux,  Talamon,  Jalagtjier, 
and  TUEFIER. 

In  Germany  characteristically  scientific  work  has  been  done  by  Sonnen- 

Bl'RC;.    RlEDEL,    KROGI1  S,   and    LENZMANN. 

In  concluding  this  brief  enumeration,  I  must  not  omit  the  name  of  the 
great  Scandinavian  surgeon,  Lennander,  of  Upsala,  whose  writings  show  the 
most  scientific  extensive  comprehension  of  the  subject  in  all  its  phases. 


BIBLIOGRAPHY. 

Blackadder:  "Notices  of  certain  accidents  and  diseased  structures  "f  the  cecum  coli,  ami  of 

tin-  vermiform  appendix."     Edin.  Med.  and  Surg.  Jour.,  Is24.  vol.  22,  p.  118. 
Bright  and  Addison:  "  Elements  oi  tin-  Practice  of  Medicine."     Lond.,  1839,  vol.  1.  p    198 
l:.  il:  "Perityphlitis."     New  York  Med.  Jour.,  isTM.  vol.  is.  p.  240. 
I :i  i:i  bard:  "i  Operative  interference  in  acute  perforative  typhlitis."     New  York  Med.  Rec,  1880, 

VOl.     IS.    | 

Bi  i;m.:  "Upon  inflammation  and  perforation  of  the  cecum."  Med.  and  Chir.  Trans.,  Lond., 
]s.".7.  vol.  20:   also  "  Memoir  on  tuphlo-enteritis."     Ibid.,  1839,  vol.  22. 

Com  \m>:  "Cecum."     Diet,  of  Prac.  Medicine,  ls:;i. 

Dawbarn:  Internat.  Jour.  Surg.,  Maw  1895. 

Deaver:  "Remarks  upon  some  points  in  the  technique  of  the  operation  for  appendicitis." 
Ann.  of  Surg  .   1897,  vol.  27.  p.  81. 

DeVecchi:  "Storia  di  peritonite  diffusa,  mortale,  cagionata  da  ulcerazione  e  perforamento  dell' 
appendice  vermiforme  del  ceco."     Ann.  Univ.  di  med.,  1845,  vol.  113,  p.  5. 

Dri't  vria.N  :  "  Des  absces  de  la  fosse  iliaque  droite."     Lecons  chirurgicales,  1S39,  vol.  3,  p.  516. 

I       mutts:  "Inversion  of  the  appendix  vermiformis."     Amer.  Jour,  of  Med.  Sci.,  June,  189.5. 

Ff.vwick:  "Perforation  of  the  appendix  vermiformis."     Lancet,  1884,  vol.  2.  pp.  987  and  1039. 

Fitz:  ''Perforating  nicer  of  the  vermiform  appendix,  with  special  reference  to  its  early  diag- 
nosis and  treatment."  Am.  Jour.  Med.  Sci.,  1886,  vol.  92,  p.  32:  "The  relation  of  per- 
foratins  inflammation  of  the  vermiform  appendix  to  perityphlitis."  New  York  Med. 
Jour.,  lsss,  vol.  47.  p.  505;  '•  Appendicitis;  some  of  the  results  of  the  analysis  of  seventy- 


BIBLIOGRAPHY.  53 

two  caa in   in   the   past   four  years."      I'.o-t.    Mid.  ami  Surg.  Jour.,  1S90,  vol.  122, 

p.  619. 
Fowler:  "Observations  upon  appendicitis."     Ann.  of  Surg.,  1894,  vol.  19,  p.  347. 
Gay:  "Internal  strangulation  between  tin-  appendix  vermiformis,  which  had  become  adherent 

to  the  ilium,  ami  a  band  of  false  membrane."     Proc.  Path.  Soc.  Lond.,  1850-51. 
•  mildbeck:  "Ueber  eigenthiimliche  entzundliche  Geschwulste  in  der  rechten   Huftln-ingegend." 

I.  D.,  Wurms,  L830. 
Goulay:  " Perityphlitic  abscess."     Trans.  Path.  Soc-.  New  York  State.  1875,  p.  345. 
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1839,  torn.  4,  pp.  34.  137.  293. 
Hall:  "Suppurative  peritonitis  due  to  ulceration  and  suppuration  of  the  vermiform  appendix, 

etc."     Xew  York  Med.  Jour..  1886,  vol.  43.  p.  662. 
Hallo  well:  "Case  of  perforation  of  the  appendix  vermiformis;   death."     Am.  Jour.  Med.  Sci., 

1838,  vol.  22,  p.  127. 
Hancock:  "Disease  of  the  appendix  ceci   cured   by  operation."     Lancet,  1848,  vol.  2,  p.  ".so. 
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1836,  p.  17>7. 
Howard:  "Clinical   lecture  on   inflammation   ami    perforation   of  the  appendix  vermiformis." 

Med.  Chron.  (Montreal-.  Is5s.  vol.  5,  p.  527. 
Juilliard:  "Kyste  ovarique — etranglement  interne — operation — guerison."     Bull,  et  mem.  de 

la  Soc.  de  chir.,  1879,  torn.  5,  p.  627. 
Kronleix:  "Ueber  die  operative  Behandlung  der  acuten  diffusen  jauchig-eitrigen  Peritonitis." 

Arch  f.  klin.  Chir.,  1886,  lid.  33.  p.  507. 
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chir.,  et  phar.,  1766,  torn.  24,  p.  6.5. 
Lewis:  "A  statistical  contribution  to  our  knowledge  of  ah-res-  and  other  diseases  consequent 

upon  the  lodgment  of  foreign  bodies  in  the  vermiform  appendix,  with  a  table  of  forty 

cases."     New  York  Jour,  of  Med..  1856,  Ser.  3.  vol.  1.  p.  328. 
Leudet:  "  Recherches  anatomo-pathologiques  et  cliniques  sur  1'ulc^ration  et  la  perforation  de 

l'appendice  ileo-cecale."     Arch.  gen.  de  med.,  1859.  Ser.  .5,  torn.  14.  pp.  120.  315. 
Louyer-Yillerm  ay :  "Observations  pour  -ervir  a'  i'histoire  des  inflammations  de  l'appendice 

ihi  cecum."     Arch.  gen.  de  mecl.,  1824,  torn.  5,  p.  246. 
Mvtterstock:    "Perityphlitis."     Gerhardt's  Handbuch  der  Kinderkrankheiten,   1^80,  Bd.  4, 

p.  893. 
McBurxey:  "Experiences  with  early  operative  interference  in  cases  of  diseases  of  the  vermi- 
form appendix."     New  York  Med.  Jour.,  Dee.  21.  1889. 
Melier:  "Memoire  et  observation  sur  quelques  maladies  de  l'appendice  cecale."     Jour.gen.de 

med..  1827,  torn.  11)0.  p.  317. 
Meniere:  "Memoire  sur  des  tumeurs  phlegmoneuses  occupant  la  fosse  iliaque  droite."     Arch. 

gen.  de  med..  1828,  torn.  17.  pp.  188  and  513. 
Mestivier:  "  Observations  sur  une  tumeur  situee  proche  la  region  ombilicale  du   cot£  droit, 

occasionee  par  tine  grosse  epingle  trouvee  dans  l'appendice  vermiculaire  du  cecum." 

Jour,  de  med.,  chir.,  et  phar..  1759,  torn.   10,  p.  441. 
Mikulicz:  "Ueber    I.aparotomie    bei    Magen-  und   Darmperf oration."     Samml.    kl.    Vortrage, 

1885,  No.  262. 
Morton:   "Case   of   exploratory  laparotomy,   followed    by   appropriate    lemedial   operatii 

Trans.  Coll.  Phys.  and  Surg..  Phila.,  1887. 
Notes:  "Perityphlitis."     "Iran-.  Rhode  Isl.  Med.  Soc.,  1883,  vol.  2.  pt.  6,  p.  405. 
Parker:  "An  operation  for  disease  of  the  appendix  vermiformis  ceci."     New  York  Med.  Rec, 

1867,  vol.  2,  p.   25. 
Parkinson:  "Case  of  disease  of  the  appendix  vermiformis."     Med.  ami  Chir.  Trans..  London, 

1812,  vol.  3.  p.  57. 
Richards:  "  \  case  of  death  from  ulceration  of  the  vermiform  appendix."     West.  Jour.  Med. 

and  Phys.  Sri..  1837,  vol.  11,  p.  376. 
Richardson-  and  Brewster  :  "Appendicitis,  etc."     Bost.  Med.  and  Surg.  Jour.,  July  14  and  21. 

1898. 


54  HISTORY. 

Sands:  "  Account  of  a  case  in  which  recovery  took  place  after  laparotomy  had  been  performed 

for  septic  peritonitis  due  to  a  perforati f  the  vermiform  appendix."     New  'i  ork  Med. 

Jour.,  1888,  vol.  17,  p.  197. 
Senn:  "  \  plea  in  favor  of  early  laparotomy  for  catarrhal  and  ulcerative  appendicitis,  with 

the  report  oi  two  cases."     Jour.  Amer.  Med.   ^ssoc,  Nov.  2,  1889 
Symonds:  "ihi  a  case  in  which,  at  the  suggestion  of  the  late  Dr    Mahomed,  a  calculus  was  re- 
moved from  the  vermiform  appendix  for  the  relief  of  recurrent  typhlitis."     Lancet,  1885, 

vol.  l.  p   895. 
Treves:  "Relapsing  typhlitis  treated  by  operation."     Med.  and  Chir.  Trans.,  Lond.,  1888,  vol. 

71.  p.  165;   Lancet,  1888,  vol.  1.  p.  527;  and  letter  to  editor  Phila.  Med.  News,  Nov.  5, 

1892. 
Volz:  "Die  durch  Kothsteine  bedingte  Durchbohrung  des  Wurmfortsatzes,  etc."     I.  D.  Carls- 

ruhe,  1846 
Weqeler:  "  Historia  enteritiditis  malignae  et  singularis  calculosi  concrementi."     Jour.  de  mod., 

chir.,  et  phar.,  1813,  turn.  28,  p.  384 
Weber:  "  Abscess  of  the  vermiform  appendix."     New  York  Med.  Jour.,  lsyi,  vol    II.  p.  112. 
With:  "Peritonitis    \ppondieularis,"    etc.    Nordiskl    Mediciniskt  Arch.,  Hand  7.     Abstract  in 

Lond.  Med.  Rec,  vol.  8,  p.  218. 
Worcester:  "Treatment  of  appendicitis."      Ann.  of  (<yn.  and   I'ediat.,  May,   18i)2. 


CHAPTER    IV. 

ANATOMY. 

EMBRYOLOGY  OF  THE  VERMIFORM  APPENDIX.     DIFFERENTIATION   BETWEEN 
THE   APPENDIX  AND  THE  CECUM.     COMPARATIVE   ANATOMY. 

THE  EMBRYOLOGY  OF  THE  VERMIFORM  APPENDIX. 

The  anatomical  structure  as  well  as  the  topography  of  the  vermiform  ap- 
pendix and  the  adjacent  portions  of  the  intestinal  tract  in  the  adult  present 
so  many  deviations  from  the  normal  that  it  is  difficult  to  arrive  at  an  under- 
standing of  their  different  perplexing  variations.  These  difficulties  become 
reduced  to  a  minimum,  however,  by  a  study  of  the  embryology  of  the  por- 
tions of  intestine  concerned.  A  brief  description  of  the  origin  and 
development  of  the  vermiform  appendix  will,  therefore,  be  given,  based  on 
an  investigation  of  fifty-four  human  embryos  from  the  private  collections  of 
Prof.  F.  P.  Mall  and  Mr.  Max  Brodel. 

A  glance  at  the  embryological  life  of  the  appendix  reveals  it  to  be  morpho- 
logically as  well  as  structurally  merely  a  portion  of  the  general  cecal  pouch 
which  has  remained  in  an  early  stage  of  development. 

At  the  end  of  the  f  i  rs  t  m  o  n  t  h  of  intrauterine  life  the  intestinal  canal 
is  in  the  form  of  a  small  loop  protruding  into  the  umbilical  cord,  and  for  the 
sake  of  convenience  a  cranial  and  a  caudal  portion  or  limb  may  he  spoken  of. 
The  caudal  limb  lies  to  the  left  of,  and  usually  a  little  higher  than,  the  cranial 
(Fig.  1). 

The  cecum  arises  from  the  outer  and  somewhat  posterior  side  of  the  caudal 
limb  of  the  intestinal  loop.  It  is  visible  during  the  f  i  f  t  h  fetal  week  as 
a  slight  elevation  or  swelling,  a  short  distance  from  the  most  anterior  portion 
of  the  loop  (Figs.  1  and  28).  During  the  sixth  week  the  intestinal  loop 
lengthens  out,  the  cecal  protuberance  having  increased  in  size,  and  a  very 
slight  differentiation  in  calibre  between  the  large  ami  small  intestines  having 
become  apparent  I  Fig.  1). 

Between  the  sixth  and  seventh  weeks  the  small  intestine  in- 
creases in  length,  forming  a  number  of  loops  ami  contortions,  which  lie  within 
the  cord,  to  the  right,  partly  in  front  of  and  partly  below  and  behind  the  budding 
cecum  (Figs.  2,  3,  and  4).  The  latter  is  now  a  rounded  or  conical  projection 
with  a  broad  base,  extending  about  0.5  mm.  from  the  main  tube.  The  large 
intestine  does  not  increase  in  length   in   the  same    proportion  as  the  small 


;,f, 


\\  \TO\IY. 


intestine,  but  remains  of  very  nearly  the  same  size  until  it  begins  to  rotate 
aboul  the  small  intestine. 

The  Transient  Vermiform  Appendix  (Figs.  1.  5,  and  28).  -Between  the 
seventh  and  eighth  weeks  a  minute  process  is  almost  invariably 
found  at  the  tip  of  the  cecum.  It  appears  at  the  inner  or  iliac  side  of  the 
cecal  extremity,  in  the  form  of  a  delicate  hud  or  prolongation  of  the  cecum, 
very  much  resembling  a  beginning  appendix.  It  is  visible  to  tin-  naked 
eye.    and    has   a    length   of   from    one   to  four  or   five  times  its  breadth.     The 


Natural  size 


Stomach  . 
lAmb.  cord 


duodenum 
colon. 


.  _      cecum 


Fics.  1. — Human  Embryo.     Six  Weeks.     Mag.  5i.     (Mall.) 

This  figure  represents  the  Lateral  and  anterior  aspects  of  the  same  embryo  with  the  umbilical  cord  rut.  open 

t<>  show  t tie  loop  of  intesl protruding  into  H      The  loop  is  c pose. I  ..f  two  limbs:  U)  the  eranial,  eommR 

from  the  stomach,  and  1-'1  the  caudal,  descending  toward  the  cloaca       \i  the  point  where  they  leave  and  enter 

the  body,  the  caudal  limb  ties  slightly  above  and  to  the  left  ..i  the  cranial     This  condition  is  re  plainly  seen 

in  the  left  diagram.     The  small  budding  cecum  maj  he  seen  on  the  Lateral  Bide  of  tLie  caudal  limb  at  about  one- 
third  the  distance  from  its  most  anterior  point.    It-  position  marks  the  division  between   small  and  larire  intestines. 


relation  of  its  position  and  size  to  the  position  and  size  of  the  cecum  some- 
times presents  a  striking  similarity  to  the  same  relations  between  the  adult 
appendix  and  cecum,  for  which  reason  this  hud  might  at  first  lie  regarded  as 
the  true  " Arilage"  (first  indication)  of  the  subsequent  appendix.  Out  of  ten 
embryos  of  this  period  (six  and  a  half  to  eighl  weeks)  the  process  was  readily 
seen  in  eight,  ami  serial  sections  of  the  whole  ileocecal  region  were  made  of  six 
of  these.  Microscopic  examination  proves  this  structure  to  be  sometimes 
merely  an  aggregation  of  cells  at  the  tip  of  the  cecum  in  the  form  of  a  short 


TRANSIENT    VERMIFORM    APPENDIX. 


57 


blunt  process.  In  other  cases  it  possesses  a  distinct  lumen,  continuous  with 
that  of  the  cecum  and  lined  by  the  same  epithelium  as  the  rest  of  the  intestine. 
This  form  of  the  cecum,  with  its  constricted  terminal  portion,  bears  a  striking 
resemblance  to  the  cecum  of  the  Mangabcy  monkey ;  in  other  cases  the  process 
is  in  the  form  of  a  cylindrical  filament  having  no  lumen,  except,  possibly,  for 
a  short  distance  at  its  cecal  extremity.     In  one  case,  however,  the  lumen  was 


Natm-J    size. 


Fig.  2. — Lateral  View  or  Human*  Embryo.  Seven 
Weeks.  (Mall.) 
The  small  intestine  has  increased  in  length,  forming 
several  convolutions  which  lie  within  the  cord  anterior 
to  and  below  the  budding  cecum.  The  latter  is  now  a 
rounded  or  conical  projection  extending  about  0.5  mm. 
from  the  main  tube.  The  caudal  limb  is  elevated  some- 
what more  above  the  cranial,  suggesting  the  subsequent 
rotation  of  the  intestine. 


Mag.  5. 

Fig.  .3.— Same  Embryo  as   Fig.  2. 

Anterior  view  of   the  intestinal   loops   within  the 

cord. 


seen  to  extend  fully  half  the  length  of  the  appendage.  We  have  thus  a  form 
of  cecum  similar  to  that  found  in  the  gibbon.  This  peculiar  budding  process 
seems  to  be  of  an  atrophic  nature,  as  in  slightly  older  embryos  (seven  and  a  half 
to  eight  weeks)  it  appears  under  the  microscope  as  a  loose  and  irregular  chain 
of  cells.  The  picture  is  characteristic  of  a  structure  which  is  about  to  vanish. 
There  are  no  signs  of  its  broadening  out  to  form  the  future  appendix,  and  in 


,->s 


ANATOMY. 


.•ill  the  eases  examined,  its  calibre  was  so  much  smaller  than  thai  of  the  distal 
portion  of  the  cecum  or  true  appendix  as  to  render  untenable  the  view  thai  it 
is  the  anlage  of  the  future  appendix.  During  the  life  "I  this  transient  appendage, 
the  cecum,  while  equal  in  width  to  the  intestine,  increases  much  in  length. 
Its  growing  end  is  round  and  blunt,  and  remains  so  during  the  entire  period 
of  its  growth.  The  peculiar  bud  at  its  tip  retains  its  original  size,  while  the 
cecum  continues  to  grow.  At  the  seven  and  a  half  weeks'  stage,  therefore,  a 
long  cecum  can  be  observed,  on  the  end  of  which  the  delicate  hud  is  still 
visible  I  Fig.  I'M.  In  subsequent  stages  this  hud  is  seen  to  become  thinner,  and, 
finally,  to  disappear,  while  the  cecum  continues  to  grow  as  before,  the  end  still 

maintaining  its  blunt  shape. 
This  disappearance  of  the  bud 
seems  to  prove  that  it  never  lie- 
comes  utilized  in  the  promotion 
of  the  cecal  growth.  It  is  very 
common  in  embryonic  life  for 
structures  to  form  and  disap- 
pear, a  large  percentage  of  the 
embryonic  tissue  being  used  up 
in  this  manner. 

The  structure  which  makes 
its  appearance  at  the  tip  of  the 
cecum,  and  vanishes  later  on, 
may  lie  a  transient  vermiform 
appendix,  similar  to  other 
transient  structures  which  are 
formed  during  embryonic  life, 
or.  as  suggested  above,  it  may 
represent  a  stage  in  the  life- 
history  of  the  human  cecum, 
which  at  one  time  more  nearly 
resembled  that  of  certain  mon- 
keys; as,  for  example,  the  Mangabey  monkey  or  the  gibbon. 

Between  the  sevenl  h  and  eighth  weeks  the  cecum,  with  its  con- 
cavity  facing  to  the  right,  increases  rapidly  in  length,  and,  as  was  said  above, 
the  formation  at  the  tip  disappears  (Fig.  28).  The  intestines  are  coiled  in  a 
round  mass  within  the  umbilical  cord,  occupying  its  proximal  portion.  Owing 
to  the  rapid  increase  in  length  of  the  small  intestine,  there  now  begins  a  rotation 
of  the  two  original  portions  or  limbs  of  the  loop  (cranial  and  caudal)  around 
each  other.  The  caudal  portion,  with  the  attached  cecum,  swings  a  short 
distance  around  to  the  left,  then  over  the  cranial  portion,  and  toward  the  right. 
In  so  doing,  the  cecum,  which  was  previously  concealed  beneath  the  coils  of 
small  intestine,  now  comes  to  lie  above  them  (Figs.  5  and  7). 


Fig.  t  Human  Embryo.  Sevem  Weeks.  (Mall,  No.  28.) 
At  the  left  is  .seen  the  embryo  in  natural  size,  20  mm. 
cervici  (-coccygeal  measure.  A  discrepancy  in  jize  between  this 
embryo  and  the  one  shown  in  the  preceding  figure  i-  probably 
due  togreatei  contraction  in  hardening  1  he  ii  mi  re  at  t  lie  riidit 
shows  the  coil  nf  intestines  lying  within  the  opened  cord  and 

■  I  i  itl mphalo-mesenteric  vein  in   its  connection  with  the 

primitive  intestine.      A.1  the  left  <>f  the  intestinal  coil  may  be 

seen  the  eeeurn.  at    whose  inner  tip  is    nmv  visible    a   tiny  pro- 
ject ion,  I  he  1 1  a  o  tent  appendix. 


RECEDING    OF    INTESTINE    FROM    CORD    INTO    BODY. 


59 


Fig.  5. — Human    Embryo.     Seven    and    a    Half    Weeks.     25    mm     Cervico-coccygeal   Measure.     (Mall, 

No.  89.) 
The  small   intestine  has  increased   rapidly  in  length,  forming  a  large  mass  of  convolutions  which  in  greater 
part  lie  within  the  cord.      The  large  intestine   lies  almost  entirely  concealed   within  the  body,  but  the  elongated 
cecum,  with  its  minute  projection  at  the  tip,  may  be  seen  near  the  junction  of  the  cord  and  the  body,  lying 
cranial  to  the  rest  of  the  intestine. 


x7 


ppend 


Fig.  6. — Human  Embryo.      Eight  Weeks.     32   mm.  Vertex-coccygeal  Measure.      (Mall,  No.  52.) 

This  figure    shows  the    last    stage    in    the  receding  of   the   intestinal  coils  from    the   cord  into  the  body.     The 

ileocecal  apparatus  lies  across  the  entrance,  while  a  small  loop  of  ileum  still  projects  into  the  cord. 


60 


AN  \TUMY. 


The  differentiation  between  large  and  small   intestines  has  now   become 
inure  marked,  and  the  cecum  may  show  a  slight   bulging  oul  al   its  upper 

extremity,  which  is  thus  differentiated  from  its  lower  or  distal  portion,  the 
appendix  (Fig.  7).  CLADO  says  there  is  no  differentiation  before  two  and  a 
half  months:  other  authors  say  that  the  appendix  is  not  a  distinct  organ  until 
tin'  sixth  or  seventh  month.  My  investigations,  however,  demonstrate  that 
these  statements  are  erroneous. 

A  well-defined   mesappendix   provided   with  an  artery  may  he  found  at  this 
stage,  hut  since  differentiation  is  as  yet  slight,  it  is  more  properly  the  posterior 


vascular  foil 


of  the  cecum,  which  later  on,  as  differentiation  proceeds,  becomes 

the  mesappendix.  Toward  the  end 
of  the  sevenl  h  week  the  in- 
testines lioiiin  to  recede  into  the 
body,  their  entrance  heini;  accom- 
plished between  the  eight  li  and 


—        I 


Fig.  7.  Human  Embryo.  Eight  Weeks.  I  M  .u  i .  No  202  I 
This  embryo  .-how-  the  intestines  mainly  outside  the 
body,  acircum  tance  probably  due  to  imperfect  development 
and  injury.  In  other  specimens  of  this  age  the  intestine* 
have  almost  completely  receded  into  the  body-cavity.  (See 
i  6  i  he  cecum  has  increased  considerably  in  length,  its 
proximal  portion  showing  a  slight  bulging  which  differenti- 
ates it  from  the  distal  portion  or  appendix.  This  marks  the 
beginning  oi  the  primary  differentiation,  the  secondary 
differentiation  taking  place  near  or  at  the  time  of  birth. 
The  transient  appendix  at  the  tip  of  the  cecum,  visible 
during  the  seventh  week,  has  now  disappeared. 


In.  S.  Human  Embryo.  Nine  \\  i  i  k> 
9-  (Br6del,  No.  15.)  Natural  Size;  Ileo- 
cecal   Apparatus    Enlarged    in    Small    I>ia- 

GRAM. 

The  intestines  lie  now  entirely  within  the 
body  and  the  growth  of  the  ileum  has  forced  the 
cecum  and  appendix  upward  in  front  of  and  just 
below  the  duodenum.  The  livei  has  been  re- 
moved in  order  i<>  show  the  proximal  coils  of 
ileum.  The  cecum  and  colon  hang  entirely  free 
on  their  mesentery  and  present  anteriorly  the 
face  which  later  becomes  posterior.  The  appen- 
dix is  bent  hack  upon  itself,  and  shows  a  slight 
differentiation  in  calibre  from  the  cecum. 


ninth  weeks  (Fig.  6).  The  cecum  then  lies  near  the  umbilicus,  and 
the  entire  large  intestine  lies  wholly  to  the  left  of  the  median  line  (Fig.  7), 
owing  to  the  pressure  exerted  by  the  rapidly  growing  coils  of  the  small 
intestine.  The  rotation  of  the  intestinal  tube  continues,  and  the  colon, 
with  the  cecum  and  appendix,  is  pushed  upward  in  front  of  the  duodenum, 
until  they  lie  just  beneath  the  liver  and  near  the  middle  line  (Tigs,  s  and  9). 
The  variations  in  the  position  of  the  cecum  and  appendix  at  the  age  of  ten 
weeks  are  shown  in  Figs.  10  and  11.  Coils  of  small  intestine  shift  to  the  left 
and  take  the  place  previously  occupied  by  the  large  intestine.  At  two 
and    a   h  a  If   months    the   cecum   generally   lies    in    a   transverse   direc- 


APPENDIX    IN    SUBHEPATIC    POSITION'. 


61 


tion  on  the  right  side  of  the  bod}',  just  beneath  the  inferior  border  of  the  liver 
(Fig.  11).     At  this  period  of  intrauterine  life  the  iliac  side  of  the  cecum  faces 


m 

■ 

V 

v  1 

,     ■ 

<f 

Fig.  9. — Human  Embryo.  Nine  to  Ten  Weeks. 
5.5  CM.  (Mall.) 
The  cecum  and  appendix  lie  near  the  middle  line, 
just  beneath  the  liver.  The  ileum  now  enters  the 
colon  from  the  left  and  from  below,  and  the  appendix 
is  bent  upon  itself  with  its  tip  pointing  upward.  The 
cecal  pouch  tapers  down  to  one-half  its  size  and  its 
distal  portion  may  now  be  considered  the  appendix. 
Coils  of  ileum  occupy  the  right  renal  region,  thus  pre- 
venting the  cecum  from  entering  the  same. 


Fig.   10. — Human  Embryo.      Ten  Weeks.     7.5  cm. 
(Brodel,  No.  18.) 
The  cecum  and    appendix  lie  near  the    middle 
line,  just  beneath  the  liver.     The  differentiation  be- 
tween them  is  well  marked. 


Fig.  1 1. — Human  Embryo.  Ten  Weeks.  (Brodel, 
No.  13.) 
The  cecum  and  appendix  have  moved  along  the 
edge  of  the  liver  toward  the  right,  and  lie  in  the  right 
hypochondriac  region.  Coils  of  ileum  intervene  be- 
tween them  and  the  kidney.  In  the  detail  at  the  left 
the  ileum  may  be  seen  to  enter  the  colon  from  below. 
The  face  which  the  ileocecal  apparatus  presents  to 
the  front  is  approximately  the  same  as  in  the  adult. 


Fig.  12. — Human  Embryo.  Eleven  Weeks.  Mag. 
1£.  (Brodel,  No.  6.) 
The  cecum  hangs  on  a  very  free  and  movable 
mesentery,  above  and  mesial  to  the  ovary.  The 
whole  ileocecal  apparatus  assumes  a  position  near 
the  mid-line  of  the  body,  a  rather  exceptional  occur- 
rence. The  appendix  lies  curled  behind  the  ileocolic 
mesentery.  The  greater  part  of  the  ileum  ami  its 
mesentery  has  been  removed  to  show   the  appendix. 


downward,  its  tip  as  a  rule  pointing  to  the  left,  the  termination  of  the  ileum 
running  in  an  upward  direction  (Figs.  9  and  11).  There  is  no  ascending  colon 
as  yet,  the  tube  skirting  along  the  free  border  of  the  liver  in  an  oblique  direction, 


62  \  V  VTOMY. 

from  right  to  left  across  the  duodenum,  under  the  stomach  to  the  splenic 
region,  where  it  curves  suddenly  down  to  form  the  descending  colon  (Fig.  8). 

On  lifting  back  the  anterior  abdominal  wall  in  embryos  of  this  stage,  the 
appendix  usually  lies  in  lull  view,  but  it  may  also  lie  coiled  behind  the  cecum 
or  parts  of  the  -mall  intestine.  The  large  intestine  ~till  maintains  the  integrity 
of  its  mesentery  ami  can  be  moved  around  freely  within  certain  limits,  there 
being  no  fusion  whatever  with  any  portion  of  the  posterior  abdominal  wall. 
Between  the  age  of  three  ami  four  months  the  cecum  occupies  the  subhepatic 
position,  immediately  anterior  to  the  right  kidney.  In  some  instances  there 
is  already  a  moderate  descent  of  the  cecum  noticeable,  and  consequently  an 
indication  of  the  ascending  colon.     The  cecal   pouch   now  points  downward 


^F 

_^ 

• 

\ 

~~W 

f- 

Fig.   13. — Human  Embryo.     Thirteen  Weeks,      j  .     (Br6del,  v..  14.) 
The  body  is  bent  somewhat    backward    in   order  to  show  the  cecum   and   appendix,  which  lie  anterior  to   the 
rttfht  kidney  in  the   picture,  probably  a  little  lower  when   in  their  normal  position.      At  the  left  is  given  a  magni- 
fied view  of  the  ileocecal  region. 

and  the  ileum  enters  from  the  left  (Figs.  12,  13,  11,  1."),  10,  17,  18,  20,  and  21). 
The  position  of  the  appendix  becomes  subject  to  many  variations.  The  retro- 
cecal type,  however,  seems  even  in  these  early  stages  to  lie  the  most  frequent. 
Between  the  fourth  and  seventh  months  the  cecum  descends  from  its  sub- 
hepatic position  (Figs.  22,  23.  24,  and  26).  Sometimes  the  descent  is  not 
complete  until  the  time  of  birth  (Fig.  27).  The  descent  is  accomplished  by 
moving  somewhat  to  the  right  and  passing  downward  anterior  to  the  kidney, 
either  directly  in  front  of  it,  or  separated  from  it  by  several  coils  of  ileum.  The 
cecum  then  approaches  its  ultimate  position  in  the  right  iliac  fossa.  The 
revolution  of  the  colon  and  cecum  through  an  arc  of  180  degrees  around  their 
own  long  axis  produces  a  change  in  the  relative  position  of  the  ileum  and  colon 
as  compared  with  Fig.  10,  the  former  now  entering  the  latter  not   from  the 


DESCENT    OF    ILEOCECAL    APPARATUS. 


63 


Fig. 


Thrff.   Months. 
10.) 


right,  but  from  the  left  and  from  below,  and  not  from  behind,  but  in  front 
(Figs.  14,  15,  and  17). 

The  fusion  of  the  mesocolon  with  the  posterior  abdominal  wall  cannot 
take  place  before  the  small  intestine  lias 
passed  out  of  the  way,  which  occurs,  as  a 
rule,  much  later.  Different  authors  dis- 
agree as  to  the  exact  period  at  which  this 
downward  movement  of  the  cecum  begins. 
As  a  matter  of  fact,  there  is  a  great  deal 
of  variation  seen  in  different  fetuses,  be- 
cause in  some  the  rate  of  descent  is  re- 
tarded by  adhesions  which  form  between 
the  cecum  and  the  organs  passed  in  its 
descent  (Figs.  20,  23,  24,  and  26),  while 
in  others  no  obstacles  present  themselves 
(Figs.  13,  15,  17,  and  18).  Grohe  states 
that  the  cecum  with  its  appendix  lies  an- 
terior to  the  kidney  at  seven  months, 
but  we  have  seen  it  advanced  into  this 
position  as  early  as  three  months 
(Figs.  12,  13,  14,  and  16).  Clado  ex- 
amined two  infants  (still-born)  in  which 
the  cecum  was  still  situated  in  front  of 
the  kidney.     As  to  the  time  when   the 

cecum  and  appendix  have  completed  their  descent,  i.  e.,  when  they  have  reached 
their  final  position  in  the  right  iliac  fossa,  we  also  find  considerable  variation. 


14. — Human  Embryo. 
(Brodel,  No. 
The  greater  portion  of  the  small  intestine 
has  been  removed,  leaving  the  mesenteric  ruffle  to 
indicate  its  position.  The  cecum  anil  appendix 
have  advanced  to  a  position  in  front  of  the  right 
kidney,  the  iliac  coils  in  the  renal  region  having 
swung  over  to  the  left,  allowing  this  juxtaposi- 
tion. The  large  intestine  anil  its  mesentery  have 
not  contracted  any  adhesions  so  far,  and,  owing 
to  the  beginning  downward  movement  of  the 
cecum,  there  is  now  an  ascending  colon  proper. 
The  appendix  is  almost  entirely  hidden  behind 
the  termination  of  the  ileum  and  its  mesentery, 
the  relation  of  the  ileum,  cecum,  and  appendix  to 
each  other  being  similar  to  that  in  the  adult,  ex- 
cept for  their  high  position.  The  small  diagram 
at  the  left  is  a  posterior  view  of  the  ileocecal 
region,  somewhat  magnified. 


7 

j*M 

BJS^-a-PP       V 

£*.. 

* 

tT       1 

\ 

A.    ' 

-e*» 

V    | 

Fig.  15. — Human  Embryo.     Three  Months,     (Brodel,   No.  11.) 
The  greater  portion  of  the  small  intestine  has  been  removed,  showing  the  ileocecal  apparatus  lying  anterior 
to  the  right  kidney.     The  .small  diagram  at  the  left  represents  the  posterior  aspect  of  t  he  apparatus,  the  appendix 
being  quite  long  and   curled   around  the  cecum.      There  are  no  adhesions  between  the  colon  and  me.-ocnloii    ml 
the  posterior  abdominal  wall. 


If  not  retarded  by  adhesions,  the  cecum  may  arrive  in  the  fossa  as  early  as  the 
f  o  u  r  t  h   in  o  n  t  h,   but  it  is  usually  later  than  this  date.      Some  authors  say 


64 


A  WTO  Ml  . 


it  is  not  until  the  time  of  birth  approaches  that  the  cecum  reaches  the  iliac 
fossa.  The  distance  between  the  right  lobe  of  the  liver  and  the  middle  of  the 
iliac  fossa  is  relatively  much  shorter  in  the  fetus  than  in  the  adult,  the  difference 
being  due  to  the  enormous  size  of  the  liver  and  the  relative  shortness  of  the 


Natural      Size 


Fio.  16. — Homas  Embryo.  Three  Months.  Three  Times  Natural  Size.  (Brodel,  No.  I.) 
The  figure  represents  a  transverse  section  through  the  lower  half  itf  the  body.  Just  beneath  the  left  kidney, 
at  the  extreme  right  of  the  section,  the  descending  colon  with  its  free  mesocolon  may  he  seen;  while  at  the  left 
of  the  picture  lies  the  ileocecal  portion  >.f  the  ititc-iiiic.  the  appendix  being  curled  up  in  a  peritoneal  pocket  be- 
tween the  kidney  and  t  he  colon  with  it  mesentery.  Vbove  an-  two  diagrams,  the  left  showing  the  region  of  the 
appendix  and  course  of  the  ileum  three  times  magnified,  while  the  right  .sketch  is  an  outline  of  the  section  in 
natural  size. 


lumbar  vertebra-  in  the  fetus  (Figs.  24,  20.  and  27).  Therefore,  as  long  as  the 
iliac  fossa  remains  situated  so  close  to  the  liver,  the  ascending  colon  must  remain 
insignificant  in  length,  ami  the  cecum  appear  lodged,  more  or  less,  in  the  sub- 
hepatic  position.     As  soon  as  the  lumbar  region  grows  in  length,  the  cecum 


APPENDIX    IX    FROXT    OF    RIGHT    KIDNEY. 


65 


Fir,.  17.— Human  Embryo.  Foukteex  Weeks.  9-  1-  cm.  (Brodel,  No.  9.) 
The  diagram  on  the  left  shows  the  organs  in  situ,  cecum  and  appendix  being  entirely  concealed  behind  loops 
of  intestine.  In  the  right-hand  picture  the  small  intestine  has  been  removed  to  show  the  topography  of  the 
large  intestine.  The  cecum  lies  anterior  to  the  right  kidney,  being  bordered  above  by  the  liver.  The  appendix 
rests  upon  the  rectum  and  its  mesentery,  the  rectum  and  sigmoid  flexure  being  abnormally  long  and  curled  up 
in  a  series  of  loops,  the  most  distal  of  which  reaches  to  the  lower  pole  of  the  right  kidney.  The  differentiation  in 
calibre  between  the  cecum  and  the  appendix  has  become  more  marked,  the  cecum  having  increased  in  size  with 
the  rest  of  the  body,  while  the  appendix  lags  behind  in  development. 


Fig.  18. — Human*  Embryo.     Three  to  Four  Months.     Natural  Size.      (Brodel,  No.   7.) 
The  lower  half  of  the  abdominal  wall  has  been  stretched  downward  somewhat  to  disclose  the  cecum  and  ap- 
pendix.    These  have  now  descended  I  "-low  the  edge  of  the  liver,  almost  to  their  ultimate  position  in  the  right 
iliac  fossa.      The  differentiation   between  cecum   and   appendix  is  marked,  the   latter  curving,   in  a  worm-like 
manner,  anterior  to  the  ileum  and  cecum. 


GO 


ANATOMY. 


FlG.  19. — Human  Fetus.      Four  Months.      9-      (Bhodel,  II.) 
On  opening  the  abdominal  cavity  in  the  manner  shown  in  ttiis  figure,  the   cecum  IS   visible  at  the  left  of  the 
picture,  but  the  appendix  remains  hidden  behind  the  folds  of  intestine.     The  next  figure  illustrates  the  same 

embryo  with  most  of  the  ileum   removed. 


Fig.  20.— Human  Fetus.  Fottr  Months. 
Same  as  the  preceding  figure,  a  large  portion  of  the  intestine  having  been  removed.  The  cecum  and  appen- 
dix lie  anterior  to  the  right  kidney,  the  ascending  colon,  cecum,  and  the  terminal  portion  of  the  appendix  having 
already  become  firmly  adherent  to  the  posterior  abdominal  wall  before  their  final  descent  into  the  right  iliac  fossa. 
Foi  'he  sake  of  clearness  the  adhesions  have  been  somewhat  emphasized.  The  differentiation  between  the  cecum 
and  the  appendix  is  not  abrupt,  the  cecum  showing  no  particular  distention.  The  point  where  it  makes  its  first 
turn  upward  marks  the  beginning  of  the  appendix.  The  latter  is  free  with  the  exception  of  its  distal  fourth, 
where  the  mesappendix  is  short  and  soon  continuous  with  the  peritoneum  of  the  posterior  abdominal  wall.  On 
account  of  the  adhesion-,  any  subsequenl  descent  of  the  cecum  to  fill  the  iliac  fossa  would  have  to  take  place  in  its 
anterior  portion,  causing  a  retrocecal  position  of  the  appendix.  The  mesappendix  is  seen  to  join  the  posterior 
abdominal  wall  close  to  the  ovarian  vessels,  a  minute  peritoneal  fold  connecting  the  two.  This  is  the  first 
stage  in  the  formation  of  the  appendico-ovarian  ligament.  It  must  be  remembered,  however,  that  only  few  fetuses 
show  this  structure. 


NON-DESCENT    OF   ILEOCECAL    APPARATUS. 


07 


descends  with  the  more  capacious  iliac  fossa,  and  the  ascending  colon  increases 
in  extent. 

On  the  other  hand,  the  cecum  may  never  reach  this  position,  if,  during  its 
descent  the  ileocecal  apparatus,  or  any  portion  of  it  becomes  adherent  to  neigh- 
boring organs,  such  as  the  kidney,  the  gall-bladder,  or  the  duodenum.  Treves 
reports  two  cases  of  adults  in  which  the  cecum  and  appendix  were  still  situated 
just  beneath   the  liver,   having  become   adherent  before  descent  took   place. 


Fig.  21. — Human  Fetus.  Four  Months.  °.  Mag.  3.  (Brodel,  III.) 
The  figure  represents  the  lower  right-hand  corner  of  the  abdominal  cavity,  the  ileum  having  been  removed 
with  the  exception  of  its  terminal  portion.  The  ascending  colon  is  very  short,  the  cecum  lying  not  far  beneath 
the  liver  in  the  right  hypochondriac  region.  The  cecum  shows  signs  of  beginning  sacculation,  which,  however, 
as  a  rule  takes  place  much  later.  The  proximal  portion  of  the  appendix  is  directed  obliquely  upward  behind  the 
termination  of  the  ileum;  it  then  bends  backward  upon  itself,  makes  another  turn,  and  curves  up  over  the  ileum, 
following  the  free  edge  of  the  ileocolic  fold.  Should  the  tip  of  the  appendix  contract  adhesions  in  this  position, 
the  subsequent  sagging  down  of  the  intestine  might  cause  strangulation. 


Concerning  this  descent  and  adhesions  see  section  on  "The  Position  of  the 
Appendix,"  Chap.  VI,  p.  118. 

G.  S.  Huntington  has  worked  out  the  development  of  the  primitive 
coils  of  intestine  in  their  relation  to  the  cecum  and  appendix.  He  divides 
the  embryonic  coils  of  the  small  intestine  into  three  main  groups:  I,  the  prox- 
imal (or  jejunal)  set  of  convolutions,  occupying  the  upper  and  left  part  of  the 
abdominal  cavity;  II,  the  distal  (or  ileal)  division  of  the  small  intestinal  con- 
volutions, lying  to  the  right  of,  and  in  the  earlier  stages  behind,  the  cecum; 
and  III,  the  convolution  connecting  these  two  portions  of  the  small  intestine 
which  occupy  the  lower  part  of  the  abdominal  cavity. 


68 


\\  ITOMY. 


Fin.  22. — Hitman   Fetus.      Four  to  Five  Mon  ins.      f,      L9  CM.      (Biiodkl,  IV.) 

This  figure  represents  the  appendix  and  other  organs   in   situ,  just    after  opening  up  the   body-cavity.     Only 

the  termination  of  the  appendix  is  visible,  and  a  -mall  portion  of  the  cecum  may  he  seen  above  it. 


Fig.  23. — Same  as  the  Preceding  Figure,  Most  of  the  Small  Intestive  Havint,  Been  Removed. 
The  r<-<  um  Lies  aol  far  beneath  \\k-  edu;e  of  the  liver,  tin-  ascending  portion  of  the  colon  being  short  and  "f 
rather  large  calibre.  For  a  short  distance  it  i-  adherent  t<.  t  he  lateral  body-wall,  and  the  entire  cecum,  as  well  as 
the  proximal  third  of  the  appendix,  are  also  bound  down  bj  >  I  le  on!  to  their  posterior  surfaces.  Whether  these 
latter  adhesions  are  the  result  <>|  a  localized  peritonitis,  or  whether  they  are  part  of  the  usual  peritoneal  adhesions, 
we  were  not  able  to  decide.  The  distal  two-thirds  of  the  appendix,  however,  remain  quite  free,  the  tip  pointing 
in  an  outward  direction.  Therefore,  in  this  case  the  cecum  and  appendix  have  become  adherent  before  reaching 
their  final  position  in  the  right  iliac  fossa.  The  adult  position  of  the  appendix  would  have  been  retrocecal  and 
partially  extraperitoneal.     Again,  there  are  adhesions  from  the  appendix  to  the  spermatic  vessels. 


APPENDIX    IX    FETUS    OF    FIVE    MOXTHS. 


69 


Fig.  24. — Human  Fetus.  Five  Months,  cf.  Mag.  H.  (Brodel,  V.) 
The  figure  shows  a  somewhat  lateral  view  of  the  abdominal  viscera  in  situ.  The  cecum  and  appendix  lie  at 
the  left  of  the  picture  just  beneath  the  liver.  The  cecum  presents  the  typical  funnel-shaped  appearance  character- 
istic of  the  fetus,  its  apex  being  directed  downward.  The  anterior  longitudinal  muscular  band  is  faintly  visible 
extending  up  and  dciwn  its  anterior  surface.  At  the  point  where  the  cecum  ends  and  the  appendix  begins,  the 
latter  makes  a  sharp  turn  upward  and  to  the  left;  after  being  hidden  for  a  short  distance  behind  a  coil  of  small 
intestine  it  reappears  and  passes  upward  along  the  external  border  of  the  cecum.  Only  the  uppermost  portion 
of  the  cecum  is  adherent,  its  remaining  portion,  as  well  as  the  entire  appendix,  being  free.  The  ileum,  however, 
is  closely  adherent  for  the  space  of  a  centimetre  or  more  near  its  termination.     (See  Fig.  25.) 


yt 

1 

:  <^yi- 

,,  *■ 

-~^ 

Fig.  25.— Appendix  Region  ok  Fetus  Shown  in  Preceding   Figure,      Mag.  \\. 

The  entire  appendix  is  now  visible,  ami  the  extent  of  the  adhesions  along  the  ascending  colon,  upper  portion  of 

the  cecum,  and  along  the  most  lateral  limb  of  the  loop  of  small  intestine,  can  be  more  clearly  seen. 


70 


ANATOM1  . 


It  is  the  distal  or  ileal  group  of  convolutions  which  affect  in  some  measure 
the  disposition  of  the  cecum  and  appendix.  At  first  these  coils  lie  behind 
as  well  as  to  the  right  of  the  cecum,  whose  apex,  together  with  the  appendix, 
is  frequently  embedded  among  them.  With  the  continued  growth  of  the  small 
intestine  the  cecum  is  pushed  further  upward  and  to  the  right;  while  at  the 
same  time  the  terminal  ileal  coils  pass  downward  and  to  the  left,  from  a  retro- 


Fxg    _'t",     -Human   Fetus.— Six    ro  Seven    Months,      f.     Natural  Size.     (Brodel,   VI.) 

The  ileum  has  been  for  the  most  part  removed,  exposing  the  larce  intestine,  which  is  very  much  convoluted 
owing  to  tlie  relative  shortness  Let  ween  li\er  and  pelvis.  The  tran.-\erse  colon  is  m  pari  ,,,\en-d  l,y  the  t-Tou  int; 
omentum.  At  the  left  of  the  picture  lie  the  cecum  ami  appendix,  which  have  not  yet  completed  their  descent 
into  the  right  iliac  fossa.  The  cecum  an.l  beginning  portion  of  the  colon  are  free  from  adhesions  along  their  pos- 
terior surfaces,  but  the  posterior  fourth  of  tin-  appendix  is  bound  down  by  adhesions  which  pass  from  it,  over  the 
spermatic  vessels,  and  become  lost  -in  the  posterior  parietal  peritoneum.  The  remainder  of  the  appendix  i>  free 
and    lies   curled    beneath    the    cecum. 


cecal  into  a  subcecal  position,  thus  permitting  a  direct  apposition  of  the  cecum 
to  the  dorsal  parietal  (prerenal)  peritoneum. 

We  see,  therefore,  that  the  position  and  form  of  the  adult  cecum  and  ap- 
pendix depend  largely  upon  the  time  during  their  development  at  which  they 
come  into  contact  with  the  posterior  abdominal  wall.  If  coils  of  intestine 
remain  interposed  between  them  during  the  descent  of  the  ileocecal  portion, 


RELATION    OF    APPENDIX    TO    PRERENAL    PERITONEUM. 


"1 


it  may  reach  the  right  iliac  fossa  without  having  contracted  any  adhesions. 
This  gives  a  comparatively  free  cecum  and  pendant  appendix.  If,  however, 
the  coils  of  ileum  are  early  displaced,  and  the  cecum  and  appendix  come  into 
early  contact  with  the  posterior  abdominal  wall,  that  is,  at  a  time  before  or 
during  their  descent,  the  posterior  surface  of  the  cecum  is  apt  to  fuse  at  a  com- 
paratively high  level  with  the  abdominal  wall,  and  any  further  descent  is,  as  a 
rule,  accompanied  by  a  rotation  of  the  cecum  to  the  left  or  the  median  line  of 
the  body.  The  appendix,  if  not  individually  adherent,  follows  this  movement. 
The  append ico-cecal  junction  becomes  shifted  during  this  rotation  in  an  upward 


Fig.  27. — New-born'  Babe.  Natural  Sizt. 
This  figure  shows  the  lower  right-hand  portion  of  the  abdominal  cavity,  with  the  cecum  lying  in  the  right  iliac 
fossa,  the  ileum  having  been  drawn  aside.  The  appendix  is  coiled  in  an  S-shaped  manner  behind  the  ileum  and 
colon,  and  partly  concealed  by  them.  When  it  again  becomes  visible,  it  lies  beneath  the  liver  in  front  of  the  right 
kidney,  while  the  tip  rests  upon  the  colon.  Owing  to  the  large  liver  and  shortness  of  the  lumbar  region,  the  ascend- 
ing colon  has  not  yet  had  a  chance  to  develop.  Both  the  cecum  and  appendix  are  entirely  free  along  their  whole 
extent.  Note  the  beginning  sacculation  of  the  large  intestine  in  contradistinction  to  the  round  tube  of  the  previous 
stages. 

and  posterior  direction,  the  appendix  itself  pointing  in  varying  ways,  upward, 
downward,  outward,  or  toward  the  spleen,  according  to  the  length  of  its  mesen- 
tery. 


DIFFERENTIATION   BETWEEN   APPENDIX   AND   CECUM. 
The  embryology  of  the  appendix  teaches  us  that  it  is  a  retrogressive  organ: 
i.  e.,  in  the  human  being  it  does  not  maintain  the  degree  of  development  it 
reached  in  the  fetus.     AVe  are  therefore  compelled  to  regard  the  appendix  as 
merely  the  distal  portion  of  the  original  cecum. 


72 


ANATOMY. 


i  of 

magnified  Ileum .     f 


5 


'> 


0,5       0.5 

6  v 

S       0,5 


Figs.  28,  29.  30,  and  31  are 
a  complete  series  of  ceca,  be- 
ginning with  the  earliest  indica- 
tion of  its  formation  I  five  weeks) 
and  ending  with  the  adult  form, 
all  drawn  on  the  same  scale.  To 
the  figures  arc  added  measure- 
ments of  the  calibres  of  the  in- 
dividual portions  of  t lie  ileocolic 
apparatus.  Up  to  the  age  of 
twelve  weeks,  enlargements  of 
ten  times  natural  size  are  given; 
later  stages  are  drawn  natural 
size. 

This  series  demonstrates  that 

the  differentiation  occurs  in  two 
distinct  stages,  a  'primary,  be- 
ginning at  about  the  e  i  g  h  t  h 
\\  e  e  k  of  embryonic  life,  and  a 
secondary,  making  its  appear- 
ance at   1)  i  r  t  h. 

Beginning  with  the  primitive 
form,  we  find  that  from  the 
fifth  w  e  e  k  up  to  the 
s  e  v  e  n  t  h  w  e  e  k  the  cecum 
is  of  the  same  width  as  the  rest 
of  the  intestine.  Its  length  in- 
creases during  this  period  con- 
siderably,  and  may  at  seven 
week-  amount  to  from  seven  to 
eight  times  its  thickness. 

The  ■primary  differentiation 
into   a    larger   proximal    pouch 


Fig.  28. — The  Development  of  the  Appen- 
dix FROM  THE  Ar.F.  OF  KlVE  TO  SEVEN 

Weeks. 

The  intestine  has  l>een  drawn  in  the 
tion  occupied  in  the  adult,  i.  e.,  colon  above, 

ileum  approaching  it  fr below  and  from  the 

left.  Note  the  position  of  the  transient  ver- 
miform appendix  at  the  tip  of  the  cecum. 
The  cecum  crows  in  lennth,  the  tra 
appendage  disappears,  and  the  -uhsequent 
appendix-  i-  produced  by  a  relative  narrowing- 
down  of  the  distal  portion  of  the  cecum.  The 
diameters  of  the  ileum,  colon,  and  cecum  (ap- 
pendix) are  mven  in  millimetres. 


PRIMARY    DIFFERENTIATION. 


73 


Width  of 


and  smaller  distal      Natural         10  limes  magnified  """ 

,     •  size  Ileum,  Lolon,  (-ecum(App 

portion        begins 

generally  after  the 


transient  process 
at  the  cecal  tip 
has  disappeared. 
While  this  differ- 
entiation varies  in 
different  embryos, 
like  many  other 
features  of  this 
variable  organ,  it 
generally  takes 
place  at  the  age  of 
between  s  e  v  e  n 
and  eight 

weeks. 

At  eight 
week  s  we  first 
begin  to  observe 
a  decrease  in 
thickness  of  the 
distal  portion  of 
the  cecum  as  com- 
pared with  the 
rest  of  the  intes- 
tine. It  is  found 
to  be  between 
two-thirds  and 
one-half  the  width 
of  the  colon.    The 


Fig.  29— The  Develop- 
ment of  the  Appen- 
dix     BETWEEN     THE 

Ages  of  Eight  and 
Twelve  Weeks. 
The  distal  portion  of 
the  cecum  is  narrower 
than  the  proximal  pouch, 
the  differentiation  begin- 
ning at  the  eight-weeks 
stage  (primary  differenti- 
ation). We  have  now  to 
deal  with  an  appendix. 
The  variations  in  the  posi- 
tion of  the  appendix  are 
few.  the  pendant  type 
predominating. 


n 


S  8  weeKs 


.7      '     0,75>TiTri     C/rO-m-m 


■ 


0,7    0,8    C,T5 


• 


0,8    0.9    0,5 


V*'  9  weeKs 


0,8    0,9    0,45 


10  weeKs 
1,0       1,0      0,5 


74 


ANATOMY. 


iira!  size. 
3  months 

1L.     Col.    App.  a.  col.  App. 

1,0mm  1,0mm  0,7m"l  2         2  1,4 

.I'-,  i  lorrtl i 

& 

l,S       1,5      1  1,5    %    i;a 

II.    3  -mi 
i   Col.  3,5 
App   1,3 


II.      3    n  in 

V/a  mo.  \       ,         Col.  3,5 

App.  1. 5 


>mo. 


3»p 


II.     3 
Col.   3,5 
App.  1,5 


« 


WO 


3 
1.8 


diminution  in   calibre  may  be  sudden  or 

gradual,  i.  c,  funnel-shaped.  II  the  cecum 
forms  an  acute  angle  with  the  colon,  we 
notice  a  kink  at  the  junction  between  the 
wide  and  the  narrow  portions.  This  is 
most  probably  the  form  which  develops  in 
later  life  into  a  rounded  bulging  cecum  with 
the  appendix  hidden  behind  the  ileocecal 
junction. 

Prom  n  i ne  to  t  w  e  l  v  e  w  e  e  k  s 
the  ileocecal  apparatus  grows  in  size  with- 
out changing  the  relative  measurements  of 
its  constituents.  The  narrow  distal  por- 
tion of  the  cecum  is  still  about  one-half 
the  width  of  the  small  and  large  intestines, 
its  length  continuing  to  vary  between  six 
and  eight  times  its  thickness.  The  proxi- 
mal portion  of  the  cecum  becomes  now  the 
focus  of  interest,  in  so  far  as  it  bulges  out 
to  form  a  pouch  which  renders  it  consider- 
ably larger  in  calibre  than  the  ileum  and  the 
colon.  This  pouch  may  involve  a  portion 
of  the  colon,  but  is  usually  confined  to  the 
region  of  the  ileocolic  junction. 

From  the  age  of  three  months 
up  to  six  months  the  differenti- 
ation between  the  cecal  pouch  and  its 
narrowing  distal  extremity,  the  appendix, 
becomes  more  and  more  pronounced. 
While  the  ileum  becomes  slightly  smaller 


Fio.  30. — The  Development  of  the  Appendix  between 
the  Ages  of  Three  and  Seven  Months. 
From  now  on,  the  stages  are  represented  natural  .size. 
As  the  appendix  grows,  it  position  becomes  subject  to  many 
irregularities,  most  of  which  are  traceable  to  mechanical  in- 
fluences exerted  by  the  mesappendix  and  adhesions  with  the 
posterior  abdominal  wall. 


Fig.  .31.— The  Development  of  the  Appendix  from  the 
New-born  to  the  Adult  Stage. 
The  sacculations  of  the  lame  intestine  are  beginning  to 
appear,  causing  a  still  greater  discrepancy  between  the  di- 
ameter- <.f  the  appendix  and  cecum  (secondary  differenti- 
ation!. The  third  figure  on  this  plate  shows  a  persistence 
of  the  fetal  type.  i.  c,  a  funnel-shaped  junction  between 
the  cecum  and  appendix. 


I 


Natural  size 


Fig.  31. 

7.". 


SECONDARY    DIFFERENTIATION.  77 

than  the  colon,  the  appendix  decreases  rapidly  in  thickness  as  compared 
with  the  colon,  and  at  the  sixth  month  it  is  only  about  one-third  the 
width  of  the  large  intestine.  Owing  to  this  decrease  in  thickness,  the  length 
of  the  appendix  must  now  necessarily  appear  more  considerable;  and  we 
find  that  it  varies  between  ten  and  eighteen  times  its  width.  The  diagram 
illustrating  the  relation  of  the  parts  between  six  and  seven  months 
represents  the  arrangement  existing,  except  for  individual  differences,  up 
to  term.  The  colon  is  somewhat  larger  than  the  ileum,  perfectly  cylindrical  and 
regular,  and  resembles  the  small  intestine  in  form.  There  are  no  pouches 
and  no  isolated  longitudinal  muscular  bands,  as  in  the  adult  largo  intestine. 
The  longitudinal  coat  is  of  equal  thickness  all  around  the  colon,  cecum,  and 
appendix.     The  latter  is  about  one-fourth  the  thickness  of  the  large  intestine. 

About  the  time  of  birth  a  secondary  differentiation  of  the  appendix  from  the 
cecum  takes  place,  producing  changes  in  the  Jatter  which  give  rise  to  the  char- 
acteristic sacculation  of  the  large  intestine  in  general,  and  of  the  cecum  espe- 
cially. It  is  significant  that  this  sacculation  makes  its  first  appearance  just 
at  the  time  when  intestinal  contents  begin  to  enter  through  the  ileocecal  junc- 
tion. The  walls  of  the  cecum  and  colon  are  in  this  manner  subjected  to  a 
pressure  from  within  which  causes  the  longitudinal  muscular  coat  to  separate 
into  three  bundles,  between  which  the  inner  coats  bulge  out  in  pouches,  pro- 
ducing, in  a  sense,  hernial  protrusions  covered  by  circular  muscle.  The  trans- 
verse furrows  between  the  pouches  are  due  to  the  constricting  influence  of  the 
larger  vessels.  There  are  a  few  thin  longitudinal  fibres  left  to  cover  the 
pouches,  but  the  great  bulk  remains  in  the  longitudinal  bands.  The  sepa- 
ration of  the  longitudinal  muscle  does  not  involve  the  appendix,  and  so  we  find 
the  three  bands  converging  toward  the  root  of  the  appendix,  in  order  to 
become  continuous  with  it-^  longitudinal  muscular  coat. 

We  know  that  the  peristaltic  contractions  of  the  colon  in  a  distal  direction 
are  in  certain  intervals  interrupted  by  a  reversed  contraction,  which  might  be 
considered  as  the  cause  of  the  greater  distention  of  the  cecal  pouch  as  compared 
with  the  colon  (Cannon). 

Between  the  distention  of  the  cecum  and  colon  in  the  newborn  and  adult 
there  is  noticeable  a  steady  increase,  and  if  we  compare  the  width  of  the  ap- 
pendix with  that  of  the  cecum  in  the  different  ages  concerned,  we  find  that  it 
amounts  in  the  n  e  w  b  o  r  n  to  one-third  to  one-fourth  the  cecal  diameter, 
while  in  the  eight-months-old  child  it  is  one-fourth  to  one- 
fifth;  at  eight  years  it  is  one-sixth  to  one-seventh;  and  in  the 
a  d  u  1 1,    about    one-eighth. 


COMPARATIVE   ANATOMY. 
From  the  standpoint  of  comparative  anatomy  the  appendix   vermiformis 
must  be  regarded  as  an  undeveloped  cecum.     If  the  appendix  in  the  human 


78  ANATOMY. 

subjecl  were  expanded  to  the  size  of  (he  caput  eoli,  the  whole  diverticulum 
would  closely  resemble  the  ceca  of  many  mammalia.  II.  on  the  other  hand, 
in  a  long  mammalian  cecum  the  distal  portion  had  not  developed  in  proportion 
to  the  rest,  a  cecum  and  appendix  would  then  be  produced  which  would  com- 
pare with  the  like  named  parts  in  the  human  subject. 

We  must  therefore  consider  the  entire  cecal  apparatus  from  a  comparative 
standpoint,  in  order  to  understand  the  special  significance  of  the  human  vermi- 
form appendix. 

The  entire  alimentary  canal  of  all  vertebrates  is  found  to  respond  with  great 
readiness  in  its  structure  to  variations  in  functional  demand.  'Hie  kind  and 
quantity  of  the  food  habitually  taken,  and  the  rale  of  the  tissue  metabolism — 
whether  rapid,  as  in  warm-blooded  animals,  or  slow,  as  in  cold-blooded  ones — 
.ue  some  of  the  chief  factors  which  influence  the  morphology  of  the  alimentary 
canal. 

The  changes  in  anatomical  structure  in  response  to  physiological  demand 
are  most  marked  in  the  region  of  the  ileocolic  junction  where  the  cecum  and 
appendix  form. 

As  HUNTINGTON  points  out,  all  the  varieties  of  cecal  apparatus  met  witli 
in  different  species  can  lie  traced  to  one  common  primitive  type,  from  which 
they  have  all  developed  in  accordance  with  varying  conditions  of  alimentation. 
A  few  principal  structural  types  derived  from  this  common  primitive  type 
include  all  the  various  forms  of  cecum.  "All  of  the  main  types  of  ileocolic 
junction  are  found  within  a  very  limited  zoological  range,  as  within  the  confines 
of  a  single  order.  *  *  *  The  members  of  these  zoological  groups,  while 
united  by  certain  common  anatomical  characters,  such  as  the  reproductive 
system  and  dentition,  differ  widely  in  habit  and  in  the  kind  and  quantity  of 
the  food  normally  taken.  These  differences  in  the  method  of  nutrition  have 
impressed  their  influence  on  the  structure  of  the  alimentary  canal  and  have  led 
to  the  evolution  of  varying  and  divergent  types  of  ileocolic  junction."  Xo  re- 
liable classification  of  the  vertebrate  groups  therefore  can  lie  made  from  the 
character  of  the  cecum  and  appendix. 

The  function  of  the  cecal  apparatus  is  as  follows: 

It  increases  the  extent  of  the  intestinal  mucous  surface  for  secretion  and 
absorption,  and  prolongs  the  period  during  which  the  contents  of  the  canal 
are  retained  for  digestion  and  absorption.  The  cecal  pouch  acts  as  a  reservoir 
in  which  partly  digested  substances,  mixed  with  the  secretion  of  the  small 
intestine,  are  retained  for  a  longer  or  shorter  time  in  order  that  the  process  of 
absorption  may  he  completed. 

Among  the  Herbivora,  e.g.,  the  Ungulates  and  Rodents,  whose  food  con- 
tains a  comparatively  small  amount  of  nutriment  in  proportion  to  its  bulk 
and  requires  a  longer  time  to  digest,  we  find  the  most  complicated  and  highly 
developed  cecal  apparatus;  while  in  carnivorous  animals,  whose  food  is  con- 
centrated, easily  and  rapidly  digested,  and  contains  little  non-nutritive  material, 
the  cecum  appears  as  a  reduced  or  even  rudimentary  organ. 


COMPARATIVE    ANATOMY.  rJ 

Beginning  with  the  lower  orders,  we  find  in  fishes,  Dipnoi,  and  Amphibia 
an  undifferentiated  intestinal  tract;  i.e.,  no  distinction  between  small  and 
large  intestine,  and  therefore  no  ileocecal  valve.  The  differentiation  between 
mid-gut  and  hind-gut  is  marked  in  some  species  by  a  circular  constriction. 
In  many  reptiles,  however,  especially  in  Saurians,  an  ileocolic  valve  and  cecum 
are  present.  The  cecum  is  simple,  is  said  to  lack  glands,  and  merely  acts  as  a 
temporary  receptacle  for  certain  rejected  foods.  Among  birds  the  cecum  is 
found  in  all  but  a  few  families.  It  has  advanced  somewhat  in  function,  for  a 
marked  change  is  noticed  in  the  food  on  passing  from  the  middle  to  the  end 
portion  of  the  intestine,  due  to  the  presence  of  two  large  blind  pouches  or  ceca 
situated  at  this  point. 

Gegexbauer  says  that  these  two  ceca  have  developed  from  an  originally 
single  one.  The  ceca  in  different  birds  vary  greatly  in  size  and  length.  They 
may  be  in  the  form  of  short  appendages,  or  of  enormous  blind  pouches  exceeding 
the  main  intestine  in  length.  Their  purpose  is  to  increase  the  extent  of  the 
mucous  surface.  The  longest  ceca  are  found  in  vegetable-eating  birds.  In  birds 
of  great  locomotive  power,  which  take  daily  flights  and  make  annual  migrations, 
the  increased  energy  in  the  animal  and  vital  functions  is  applied  also  to  the 
work  of  digestion,  and  a  simpler  intestinal  canal,  with  small  or  no  ceca,  suffices 
for  the  purpose.  But  in  those  species  where  the  process  of  digestion  is  slow, 
an  additional  complexity  of  the  alimentary  canal  is  required  for  the  purpose 
of  retaining  the  chyme  somewhat  longer  in  its  passage.  The  enlarged  ceca 
of  such  birds  afford  the  requisite  amount  of  mucous  surface.  The  cecum  acts, 
therefore,  as  a  second  stomach  for  the  purpose  of  holding  the  food  longer,  and 
thus  extracting  from  it  a  fuller  amount  of  nutriment.  Those  birds  which  can 
obtain  their  food  easily  and  in  ample  quantities  do  not  require  as  long  ceca 
as  those  which  have  more  difficulty  in  this  respect. 

Birds  which  swallow  stones  and  other  foreign  bodies  to  aid  in  the  digestion 
of  their  food  require  a  free  passage  for  these  through  the  intestinal  canal,  which 
is,  therefore,  generally  short  and  of  uniform  diameter.  In  order  to  extract  a 
greater  quantity  of  chyle  from  the  food,  it  is  detained  for  a  time  in  two  large 
ceca  which  communicate  with  the  intestines  by  orifices  too  small  to  admit 
pebbles  or  undigested  seeds.  The  food  mixes  here  with  the  cecal  secretions, 
and  the  due  proportion  of  nutriment   is  extracted. 

There  is  a  definite  relationship  between  the  length  of  the  cecum  and  that 
of  the  large  or  end-intestine,  a  long  end-intestine  corresponding  to  a  long  cecum, 
and  vice  versa. 

Almost  all  mammalia  are  provided  with  a  cecum,  a  single  organ  which 
varies  both  in  form  and  size.  The  size  bears  an  important  relation  to  the  kind 
of  nourishment;  meat-eating  or  carnivorous  animals  possess  a  small  and  simple 
cecum,  or  none  at  all.  while  in  herbivorous  animals  it  is  large  and  may  even 
exceed  the  length  of  the  body.  Among  those  animals  which  have  a  mixed 
diet,  such  as  many  rodents,  the  wombat,  apes,  and  man,  a  part  of  the  cecum 


so 


ANATOMY. 


undergoes  a  more  or  less  marked  retrogressive  change,  so  thai  it  remain-  as  a 
thin,  worm-like  process  attached  to  the  otherwise  well-developed  cecal  pouch. 
This  condition  points  to  a  time  when  the  appendix  and  cecum  were  of  the 
same  size,  a  retrogressive  change  having  taken  place,  due  to  changed  nutritive 
conditions.  That  this  time  does  not  lie  very  far  back  from  man  is  indicated 
by  the  fact  that  the  entire  blind  pouch  of  the  fetus  and  new-horn  possesses  a 

relatively  large  size  to  that  of  the  adult    (GROHE). 

The  arrangement  of  the  stomach  also  influences  the  size  of  the  cecum.  In 
single-hoofed  animals  with  a  single  stomach,  the  cecum  is  better  developed 
than  in  split-hoofed  animals,  which  chew  their  food  twice,  and  which  are 
provided  with  more  than  cue  stomach. 

Grohi:: examined  the  cecal  secretion  of  an  ass  and  demonstrated  the  presence 
of  an  active  digesting  substance,  especially  for  albuminous  and  starchy  food. 

The  various  types  of  the  ileocolic  region  and  of  the  cecum  in  the  vertebrates 
are  comprehensively  described  and  pictured  by  Huntington.  The  follow- 
ing is  a  short  abstract  of  his  elaborate  chapter  on  this  subject,  which  is  of  value 
in  demonstrating  the  relation  of  the  human  type  to  the  forms  found  in  other 
vertebrates.  His  classification  has  been  maintained,  while  the  pictures  are 
partly  original  and  partly  combinations  of  his  diagrams  and  photographs  of 
specimens  contained  in  his  volume:  The  Anatomy  of  the  Hu man  Peritoneum 
and  Abdominal  Cavity,  1003. 

Primitive  Type  (Fig.  32).  Straight 
tube  without  distinction  between  small  and 
large  intestine.  Cyclostomata  (subclass  of  fishes), 
mudpuppy,  etc. 

From  this  fundamental  type  the  following 
main  groups  branch  out : 


Fig.  32. 


1.    Symmetrical  Form. 


Small  and  Large  Intestine  in  Direct  Linear 
Continuity. 

(Fig.  33. )  1 .  Annular  constriction. 
(Ring  valve.)  Many  amphibians,  and  as  re- 
duction form  in  arctoid  group  of  carnivora  in 
mammals.     (Polar  bear.) 


Differ  e  ntiation      in 

a  r  g  e     a  n  d    small    i  n  I  e  s- 


(Fig.     34.) 
c  a 1 i b r e  of 
tines    (f  unnel-sh  a  p  e d).     Great  anteater 
two-toed  sloth,  bull  frog,  pond  turtle. 


(Fig.  35.)  3.  Same,  but  abrupt.     Nine- 
banded  armadillo,  alligator  (mississippiensis). 


Fig.  35. 


TYPES    OF    ILEOCOLIC    REGION. 


SI 


(Fig.  36.)  4  .  Two  cecal  pouches. 
American  manatee,  another  armadillo,  many 
carnivorous  birds. 


(Fig.  37.)  5.  Long  cecal  pouches  of 
h  e  r  b  i  v  o  r  o  us  b  i  r  d  s.  (Long  narrow  neck 
and  small  orifices.)  Goose,  hen,  owl,  loon,  red- 
breasted  merganser,  cassowary,  ostrich,  etc. 
Ceca  in  carnivorous  birds  are  verv  short. 


( Fig.  38.)   (3.  Short     cecal      p  ouches, 
narrow    neck.       Little  anteater. 


Fig.  36. 


Fig.  37. 


Fig.  38. 


II.  Asymmetrical  Development  of  Single  Cecal  Pouch.  Small  and 
Large  Intestine  in  Direct  Linear  Continuity. 
(Fig.  39.)  1.  Bulging  out  of  large 
intestine  distal  to  ileocolic  junc- 
tion and  opposite  mesenteric  at- 
tachment. Pond  turtles,  three-toed  sloth. 
(Human  embryo  of  five  weeks.) 


Fig.  39. 


(Fig.  40.)  2.  Single  lateral  cecal 
pouch.  Anaconda,  Tamandua  anteater. 
(Human  embryo  of  six  weeks.) 


1  ig.  40. 


(Fig.  41.)  3.  Prolongated  pouch 
and  reduction  in  calibre  (resembling 
one  of  the  two  ceca  of  birds).  Duck  mole,  spiny 
anteater. 


Fig.  41. 


82 


ANATOMY. 


I  ig.  12. 1  4.  S 1  i gh  1 1  y  c ur  ved  pouch, 
ii  ii  red  net  i  o  o  in  cali  l>  r  e.  Capuchin- 
tnonkev. 


(Fig.  43.)  •">.  Long,   more  or  less    con- 
voluted   pun  cli.     Dog,  wolf,  jackal,  fox. 


Fig.  43. 


III.  Rectangular  Ileocolic  Junction;  Cecum  in  Direct  Linear  Con- 
tinuity with  Colon. 

(Fig.  44.)  Type  form.  The  cecum  ceases 
to  be  a  lateral  appendage  to  the  intestinal  canal 
and  appears  as  a  caudal  prolongation  of  the  colon 
beyond  the  ileocolic  junction.  The  large  majority 
of  mammalia  belong  in  this  group.  The  type 
form  is  found  in  the  opossum.  (Human  embryo 
of  seven  weeks. ) 

The  following  subdivisions  of  this  type  are  to 
he  made : 


I  IG.   41, 


I  ig.  45. 


( Fig.  45.  i  (A  I  !.  Cecum  long  a  n  d 
c  u  r  v  i'  il,  f  o  r  m  i  n  #  a  h  o  o  k,  li  e  □  ding 
t  o  w  aril  i  1  e  u  in.  P  o  u  c  li  il  i  m  i  n  is  h  i  n  g 
gradually  in  calibre  toward  dis- 
tal e  n  d.  Large  group  of  new-world  monkeys 
(spider  monkey,  marmoset),  kangaroo.  (Human 
embryo  of  nine  weeks.) 


(Fig.  4(i.)  2.  Reduction  of  distal 
end  o  f  c  e  c  u  m  t  o  for  m  a  n  a  p  p  e  n  d  i  x. 
Anthropoid     apes     (orang,    chimpanzee,     gorilla, 


gibbon  i  and  man. 


Fig.  46. 


RECTANGULAB    ILEOCOLIC   JUNCTION. 


s:: 


(Fig.  47.)  (B)  1.  Wide  cecum  of 
varying  length;  without  reduc- 
tion  of   en  d.     Lion,  hyena. 


(Fig.    48.)     2.    Slight     reduction     of 
terminal  p  o  r  t  i  o  n.     Aardwolf,  harbor  seal. 


(Fig.  49.)  3.  Increased  reductio  n, 
formation  of  tapering  appendix. 
Puma,  red  lynx,  mongoose,  palm-cat  of  India. 


(Fig.  50. )  4.  G  r  a  d  u  a  1  e  1  i  m  i  n  a  t  i  o  n 
o  f  p  o  u  c  h,  a  p  p  r  o  a  c  hi  n  g  primitive 
type  of  straight  intestinal  tube 
(annular  pylorus-like  valve).  Great  anteater, 
two-toed  sloth,  brown    coatimundi,  raccoon-fox. 


( Fig.  51.)  5.  C  o m p  1  e t e  eliminati  o  n 
o  f  p  o  u c  h  ;  p  r  i m i  t  i  v e  t  y  p e  rest  o r  e  d 
(no  valve).  Black  bear,  polar  bear,  weasel,  rac- 
coon, bat. 


(Fig.  52.)  (C)  1.  Wide,  short,  cecal 
pouch,  e  i  t  h  e  r  blunt  and  g  1  o  b  u  1  a  r, 
or  s  1  i  g  h  t  1  y  p  o  i  n  1  e  d.  Chacma  baboon, 
olive  baboon,  vellow  baboon,  bearded  monkev. 


Fig.  4s. 


Fig   49. 


Fig.  50. 


Fig.  51. 


Fig.  52. 


84 


ANAT0M1  . 


(Fig.  53.)  2.  I!  c  (1  ii  c  ed  distal  e  n  d, 
f  o  r  in  i  n  g  cit  li  c  r  f  air]  y  distinct  a  p- 
p  end  a  g  c  o  r  I  a  ]>  e  r  i  o  g  distal  e  x- 
t  re  in  i  t  y.     Collared  peccary,  American  tapir. 


IV..  53. 


IV.   Cecal  Apparatus  Combined  with   Structural  Modification  of  Ad- 
jacent Portion  of  Colon. 

The  structures  are  highly  developed  and  complex  in  their  form,  indicating 
that  the  food  of  the  animal  is  bulky  and  difficult  to  digest.  (Ungulates  and 
Rodents. ) 

(Fig.  54.)  1.  Primitive  form  of  struc- 
tural changes  in  colon,  combined  with  absence 
of  cecal  pouch.  Development  of  spiral  mucous 
fold  in  lumen  of  colon,  increasing  secreting  and 
absorbing  surface,  and  retarding  movement  of 
intestinal  contents  in  short  and  straight  tube. 
Python,  anaconda,  shark,  lung  fish.  Among  mammalia,  herbivorous  and  omni- 
vorous animals  possess  mucous  folds,  the  plica1  of  the  colon,  which  resemble  this 
spiral  fold.     Carnivora  have  a  smooth  colic  mucosa. 


Fig.  54. 


( Fig. .")."). )  2.  L  a  r  g e,  c  apacious 

smooth-walled     and     of    uniform    calibre,    spiral 


c  e  c  u  m, 


smootn-waiieu     ami     oi     unnoriii     canine,    spiral 
fold  in  colon.     Rat,  mouse,  Bezoar-goat,  nilghai. 


Fig.  55 


(Fig. 56.)  3.  Large,  sacculated  cecum, 
provided  in  its  interior  with  spiral  valve,  vary- 
ing in  extent.  Terminal  portion  of  cecum  devoid 
of  spiral  fold,  tapering  to  form  appendix,  which 
has  a  great  number  of  lymphoid  follicles. 
Beaver,  Canadian  porcupine,  rabbit  ;  or  much 
reduced  in  length,  as  in  wombat. 


Fig.  56. 


MODIFIED    FORMS    OF    ILEOCOLIC    APPARA'I'I  -. 


85 


(Fig.  57.)  4.  Extensive  secondary  modi- 
fication of  parts  concerned.     Hare. 


CFig.  58.)  5.  Colic  modificatio  n.  form- 
ing spiral  coil  which  lias  the  effect  of  retaining  the 
food  somewhat  longer  in  the  canal  and  is  hence 
functionally  allied  to  the  cecal  apparatus.  Large 
cecum  of  uniform  calibre.  Horse,  zebu,  Japanese 
deer,  sheep,  antelope,  pig. 


(Fig.  59.)  6.  Absence  of  cecal  p  o  u  c  h, 
direct  continuity  of  intestine,  but  formation  of 
figure-8  twist  at  ileocolic  junction.  Long-tailed 
pangolin. 


Fig.  57. 


Fig.  58. 


Fig.  59. 


V.    Unique   Cecal   Apparatus    and   Colon    in    Hyrax  (Coney   or  Rock- 
rabbit). 


(Fig.  60.)  Typical  mammalian  sacculated 
cecum  at  ileocolic  junction  and.  in  addition,  fur- 
ther down,  two  symmetrical,  pointed  lateral  colic 
ceca  of  large  size. 


Fig.  60. 


86 


AN  vrmiv. 


The  study  of  the  three  constant   pericecal  folds  in  niainnialia  throws  con- 
siderable light  upon  the  development  of  this  whole  region,     In  those  species 

which  have  a  prominent  cecum,  a  fold  of  peritoneum 

will  lie  seen  to  pass  to  it  from  the  ileum.  (See  Figs. 
ill  t;.")  i  l,i,  i  h  comes  from  the  margin  of  the  ileum 
farthesl  from  its  mesentery  and  is  attached  to  the  side 
of  the  cecum   nearest    to   the   ileum.     This   is   the   true 

r  mesentery  of  the  cecum  (Treves).  The  fold  has  been 
derived  from  the  peritoneal  covering  of  the  ileum  liv 
the  budding  out  and  subsequent  growth  of  the  cecum. 
It  has  nothing  to  do  with  conveying  blood  to  it.  Tho 
supply  comes  from  the  ileocolic  artery,  which  separates 
into  two  branches,  an  anterior  ami  a  posterior. 

These  arteries  draw    the  adjacenl   peritoneum  into 

folds.  The  anterior  ileocolic  artery  gives  rise  to  an 
anterior  vascular  fold ;  the  posterior  ileocolic  artery  to 

a    posterior  vascular  fold.      These,   as  well   as   the   inter 

mediate  fold,  or  true  mesentery  of  the  cecum,  are  con- 
stant structures,  varying,  however,  in  relative  size.  In 
Ateles.  the  spider  monkey  (see  Fig.  HI),  the  anterior 
and  posterior  vascular  folds  'a  and  c)  are  of  about  the 
same  size,  the  blood-supply  to  the  cecum  being  equally 
divided  between  the  anterior  and  posterior  ileocecal  arteries.  The  intermediate 
fold  (In  i<  of  moderate  size,  distinct,  free  on  both  sides,  but  placed  nearer  the 


Fir,.  61. — Anterior  View  "i 
cai      Region     of 

\    i    I    1    I    -  ~''|T,!    R  Mo\- 

Kl    1    I. 

The  anterior  and    poste- 
rior vascular  folds  (a)  and  (c) 

en  to  reach  the  tip  of  the 
appendix,    while    the    middle 

bt lies   ■    fold     b)    ret 

I       in       growth 
i  reve 


I  p.    c,2. — Anterior  and   posterior  views  of  ileocecal  region  of  Mycetes  fuscus  (monkey),  showing  the  middle 
Ilea      fold  it'  .  and  the  anterior  (a)  and  posterior  (c)  vascular  folds,  each  carrying  an  artery  to  the  appen- 
dix (redrawn  from  Trev, 


posterior  than  the  anterior  vascular  fold.     In  Mycetes  and  in  the  Mangabey 

monkey  (Figs.  62  and  63)  the  anterior  artery  is  slightly  reduced  in  size.     The 


PERICECAL    FOLDS    IN    MAMMALIA. 


s7 


anterior  vascular  fold  is  distinct;  the  posterior  fold  is  united  with  the  inter- 
mediate non-vascular  fold. 


//Vr 


Fig.  63. — Anterior  and  posterior  views  of  ileocecal  region  of  Manga  bey  monkey,  showing  folds  (a),  (b),  and  (c) 
and  their  relation  to  the  blood-supply   (after  Treves). 


/ 


Fig.   64. — Anterior  and  Posterior  Views  of  Ileocecal  Region  of  Gibbon. 
Same  conditions  as  in  previous  figure,  only  more  marked.     The  entire  appendix  is  supplied  by  the  posterior 
branch,  which  has  lifted  up  the  peritoneum,  giving  rise  to  the  mesappendix  (c).     The  middle  fold  (b)  fuses  with 
the  mesenteriolum  near  the  appendix.     This  condition  resembles   closely  the  arrangement  found  in  man  (after 
Treves). 


Fig.  65. — Anterior  and  posterior  views  of  ileocecal  region  of  the  kain^ai  no,  showing  preponderance  of  posterior 
branch  of  ileocolic  artery  passing  in  posterior  fold  (c)  over  the  short  anterior  artery  passing  in  anterior  fold  (a). 
Middle  fold  (b)  developed  to  great  extent  (after  Treves 

In  the  gibbon  (Fig.  6-4)  and  the  kangaroo  (Fig.  65)  the  anterior  artery  is 
still  further  reduced,  while  the  posterior  artery  has  grown  out  with  the  terminal 


s^  ANATOMY. 

portion  of  the  growing  cecum,  being  its  chief  source  of  blood-supply,  and  lifting 
up  a  fold  of  considerable  extent.  In  the  kangaroo  the  posterior  vascular  fold 
(c)  fuses  with  the  intermediate  fold  (b),  while  in  the  gil>l>on  the  two  remain 
distinct  except  at  their  attachment  along  the  proximal  portion  of  the  cecum. 

In  the  human  subject  we  see  a  still  further  reduction  of  the  anterior  vascular 
fold,  or  the  "ileocolic"  fold,  as  it  is  called  in  man.  The  anterior  ileocecal 
artery  which  it  carries,  supplies  only  the  anterior  surface  of  the  upper  portion 
of  the  cecum.  The  posterior  ileocecal  artery  supplies  the  posterior  portion  of 
the  cecum  as  well  as  the  entire  terminal  portion,  the  appendix.  The  posterior 
vascular  fold,  or  the  mesentery  of  the  appendix,  has  entirely  supplanted  the 
intermediate  or  ileocecal  fold  as  a  suspensory  ligament.  The  latter  fold  fuses 
along  its  lower  border  with  the  posterior  vascular  fold,  or  mesappendix.  (See 
"  holds  and  Fossae,"  Chap.  Y.  page  (»4.) 

Thus,  we  have  a  complete  series  from  those  species  where  the  blood-supply 
to  either  side  of  the  cecum  is  symmetrical,  to  the  condition  met  with  in  man, 
where  the  chief  Mood-supply  conies  from  the  posterior  cecal  artery,  the  corre- 
sponding fold  becoming  greatly  enlarged  and  taking  the  place  of  the  original 
cecal  mesentery. 

The  reason  for  the  preponderance  of  one  of  the  cecal  arteries  over  the  other 
in  man  lies  in  all  probability  in  the  position  which  that  organ  assumes  in  its 
very  early  development  in  relation  to  the  main  source  of  blood-supply.  If.  as 
in  the  majority  of  cases,  the  posterior  surface  is  nearer  the  arterial  centre,  the 
posterior  cecal  artery  will  have  less  distance  to  go,  and  can.  therefore,  extend 
further  down  along  the  cecum.  It  follows  the  growing  tip.  the  subsequent 
appendix.  it<  branches  subdividing  and  spreading  to  either  side,  while  the 
anterior  cecal  artery  and  its  branches  spread  in  a  transverse  direction  to  supply 
merely  the  bulging  anterior  surface  of  the  cecum.     (See  Figs.  07,  68,  and  70.) 


CHAPTER  V. 
ANATOMY. 

FOLDS   AND    FOSSAE.     THE    REFLECTION    OF    THE    PERITONEUM    IN    THE  ILEO- 
CECAL   REGION.      THE    INNER    SURFACE    OF    THE    ILEOCECAL 
REGION    AND    ITS    VALVES. 

FOLDS    AND    FOSS^. 

The  folds  and  fossa1  about  the  ileocecal  region  have  been  divided  into  the 
pericecal  and  the  retrocecal  or  subcecal. 

The  pericecal  folds  lie  above  and  to  the  left  of  the  cecum  and  include  the 
ileocolic  and  ileocecal  folds  and  the  mesappendix  (see  Figs.  66,  a.  b,  and  c), 
and  are,  with  a  very  few  exceptions,  constant.  By  retrocecal  or  subcecal  folds 
and  fossa'  we  understand  those  situated  behind  and  beneath  the  cecum.  While 
the  former  are  at  once  visible,  the  latter  cannot  be  seen  without  lifting  up  the 
cecum. 

The  Ileocolic  Fold. — The  ileocolic  fold  (see  Fig.  66,  a)  lies  in  the  angle 
between  the  ileum  and  the  colon.  It  is  semilunar  in  shape,  its  free  or 
concave  margin  being  turned  toward  the  ileum.  It  springs  from  the  ventral  or 
right  (embryonic  term)  layer  of  the  mesentery  a  little  above  the  terminal 
portion  of  the  ileum,  passes  in  front  of  the  ileocolic  junction,  and  loses  itself 
on  the  anterior  surface  of  the  cecum.  The  anterior  ileocolic  artery  passes 
along  its  free  or  inner  margin  with  its  accompanying  vein,  also  several 
lymphatic  channels.  Frequently  it  contains  one  or  more  lymphatic  glands 
embedded  between  its  two  peritoneal  layers,  also  a  varying  amount  of  fat.  It 
is  found  early  in  fetal  life  (between  the  third  and  fourth  months)  and  persists 
until  old  age,  although  occasionally  diminishing  relatively  in  size,  owing  to 
the  greater  growth  or  excessive  distention  of  the  cecum,  which  derives  its 
peritoneal  covering  from  the  adjacent  folds  and  mesentery. 

The  ileocolic  fold  bounds  anteriorly  a  fossa  of  varying  extent,  which  lies 
in  the  ileocolic  angle  between  the  fold  and  the  mesentery  of  the  ileum  (big.  66, 
1).  It  is  called  the  ileocolic  fossa,  and  varies  in  depth  from  a  very  shallow  or 
scarcely  distinguishable  pocket  to  one  deep  enough  to  admit  the  thumb  beyond 
the  nail.  The  floor  of  this  fossa  is  formed  by  the  ileum  and  colon  at  their 
junction,  and  by  their  mesentery. 

Berry,  Lockwood  and  Rollestox,  Kelyxack,  and  others,  agree  in  calling 

89 


90 


ANATnMI  . 


this  fold  with  its  accompanying  fossa,  "ileocolic."  Waldeyer,  Treves, 
TUFFIER,  and  HaRTM  \nx  give  it  the  name,  "  superior  ileocecal  ";  while  Jonesco 
calls  it  the  "  ileocecal." 

Ileocecal  Fold.— The  ileocecal  fold,  which  passes,  as  the  name  indicates, 
from  the  ileum  to  the  cecum,  occupies  the  ileocecal  angle  (Fiji.  66,  hi.  ami 
lies  anterior  to  the  mesappendix.      It  is  of  varying  length,  usually  triangular 


Fig.  66.      J  he  Folds    ami  Fobs*  of  the  Ileocecal   Region. 

The  cecum  is  lifted  up  out  of  it-   !>e<l  in  the  iliac  fossa,  exposing  the  retrocecal  fold    and  fosse.    The  appendix 

has  been  drawn  out  of  the  ileocecal  fossa  to  ihov  the  mesappendix. 


but  sometimes  quadrilateral  in  outline.  Its  superior  border  is  attached  to 
the  lower  edge  of  the  ileum  for  a  distance  of  from  5.5  to  10  cm.  Its  right 
or  external  border  lies  along  the  cecum;  its  inferior  border  becomes  lost  on  the 
anterior  surface  of  the  mesappendix,  while  the  internal  bonier  is  free  and 
concave  and  forms  the  entrance  to  another  fossa. 

The  fold  consists  of  two  leaves  of  peritoneum.     The  anterior  leaf  is  con- 


ILEOCECAL    FOLD.  91 

tinuous  with  the  ventral  peritoneal  covering  of  the  ileum,  cecum,  and  mes- 
appendix;  the  posterior  leaf  loses  itself  above  on  the  posterior  side  of  the  ileum 
and  below  joins  the  cecum  and  mesappendix,  being  reflected  upward  to  form 
the  upper  part  of  the  anterior  leaf  of  the  mesappendix.  The  line  of  attach- 
ment of  the  ileocecal  fold  along  the  mesappendix  forms  an  acute  angle  with 
the  appendix,  and  is  of  variable  length;  seldom,  however,  exceeding  one-half 
the  length  of  the  mesappendix  (Fig.  66). 

The  ileocecal  fold,  unlike  the  ileocolic  and  the  mesappendix,  yet  to  be  de- 
scribed, is  not  the  bearer  of  any  important  arterial  branch.  It  is  supplied  by 
a  small  recurrent  branch  from  the  appendical  artery,  and  also,  to  a  small  extent, 
by  delicate  branches  from  the  lower  portion  of  the  ileum  and  cecum  (Figs. 
118  and  122-138).  The  fold  is  therefore  not  "bloodless."  as  Treves  calls  it, 
except  in  the  sense  that  its  origin  was  not  determined  by  blood-vessels,  as  in 
the  case  of  the  ileocolic  fold  and  the  mesappendix.  It  is  the  original  mesentery 
of  the  primitive  cecum  which  persists  in  tin.' adult,  though  slightly  altered  in  its 
lower  attachments,  and  fuses  more  or  less  with  the  mesappendix.  If  it  develops 
to  such  an  extent  as  to  resemble  in  size  the  mesappendix,  it  may  at  an  operation 
produce  the  impression  of  a  second  mesappendix  (Finney,  personal  communica- 
tion). Its  comparative  non-vascularity,  however,  will  soon  disclose  its  true 
character.  Luschka,  Peru; vox.  and  others  have  determined  the  presence  of 
muscle  fibres  in  this  fold,  which  come  from  the  longitudinal  muscular  bands 
of  the  cecum.  The  latter  continue  chiefly  along  the  appendix,  forming  its  outer 
muscular  coat,  but  a  part  of  them  have  been  seen  to  diverge  and  terminate 
in  the  ileocecal  fold.  Some  muscle  fibres  enter  it  also  from  the  inferior 
portion  of  the  ileum.  Toldt  has  seen  these  fibres  in  a  fetus  of  five  months; 
Brotscke,  in  the  embryo,  infant,  and  adult. 

Lttschka,  therefore,  attributes  to  the  fold  a  muscular  function  of  regulation 
between  the  ileum  and  cecum.  lie  maintains  that  it  assures  the  position  of 
the  parts  about  the  ileocecal  junction,  and  prevents,  by  the  contraction  of  its 
muscle  fibres,  any  obstruction  to  the  communication  between  the  small  and 
large  intestines  which  might  be  caused  by  the  ileum  assuming  a  vertical  direc- 
tion.    It  seems  doubtful  that  such  a  view  is  correct. 

The  ileocecal  fold  frequently  contains  a  quantity  of  fat.  in  some  cases  a 
considerable  amount.  It  is  occasionally,  but  very  rarely,  seen  to  take  the 
place  of  the  mesappendix.  This  occurs  if  in  early  fetal  life  the  posterior  ileo- 
colic fold  with  its  vessels  becomes  fused  with  the  middle  or  ileocecal  fold.  We 
then  have  a  broad  mesappendix  stretching  itself  between  the  free  border  of 
the  terminal  portion  of  the  ileum  ami  the  hilum  of  the  appendix.  The 
appendical  vessels  in  such  cases,  as  a  rule,  run  across  the  posterior  surface 
of  the  ileum  ami  are  adherent  to  it.  Between  the  ileocecal  fold  and  the 
mesappendix  lies  the  ileocecal  fossa,  which  opens  toward  the  left  and 
varies  in  depth   and   size  according  to  the  size  of  the  fold.     Sometimes   it   is 


92  ANATOMY. 

very  slighl — a  mere  chink;  at  other  times  the  fossa  is  deep  enough  to  admit 
several  fingers  for  a  considerable  distance,  or  even  large  enough  to  lodge  a 
small  apple. 

The  ileocecal  fold  and  fossa  have  been  described  under  a  great  variety  of 

names.     They  are  as  follows: 

1.  Superior   Ileocecal.      WALDEYEH  and  TUFFIER. 

2.  Bloodless  Fold.    Treves. 

3.  Anterior  Mesappendix.     Clado. 

4.  Ileo-appendicular  or  Anterior  Fold.     Jonesco. 

.">.    Ileocecal  Omentum.      LlTTLE. 

(').  Ileocecal  Fold.     Lockwood  and  Rolleston;  Kelynack,  Berry. 

The  Mesappendix.— X  o  r  m  a  1  A  r  r  a  n  g  e  m  e  n  t. — (Fig.  66,  c.) — The 
mesappendix,  mesenteriolum,  or  mesentery  of  the  appendix  in  a  normal 
case  has  taken  the  place,  as  will  he  later  described,  of  the  ileocecal  fold  as  a 
suspensory  ligament   for  the  appendix.     The  origin  of  its  formation  on  the 

posterior  side  of  the  cecum  is  similar  to  that  of  the  ileocolic  fold  on  the  anterior 
surface,  a  fold  of  peritoneum  having  been  lifted  up  in  each  instance,  owing  to 
the  presence  of  an  artery,  the  anterior  and  posterior  branches  respectively  of 
the  ileocolic  artery. 

When  normally  situated,  the  mesappendix  lies  partly  or  entirely  concealed 
by  the  ileum  and  its  mesentery,  which  frequently  cover  also  a  portion  of  the 
appendix  as  well. 

There  is  considerable  controversy  among  authors  on  the  subject  as  to  whether 
the  mesappendix  is  triangular  or  quadrilateral  in  outline.  As  it  is  quite  variable 
in  length,  width,  and  extent  of  attachment,  it  may  he  either. 

"The  mesappendix  arises  above  from  the  left  (embryonic  term)  or  under 
layer  of  the  mesentery  of  the  ileum.  Its  origin  is  along  a  line,  situated  a  short 
distance  from  the  intestines,  and  not  quite  parallel  with  the  margin  of  the  bowel  " 
(Treves).  This  line  forms  the  upper  or  superior  margin  of  the  mesappendix. 
Its  right  or  external  border  is  inserted  along  the  posterior  internal  face  of  the 
cecum;  its  inferior  margin  corresponds  to  the  superior  or  attached  border  of 
the  appendix,  while  its  left  or  internal  border  is  free.  The  last  is  semilunar 
in  outline,  its  concavity  facing  inward  and  upward,  and  it  is  fixed  above  to  the 
mesentery,  while  below  it  is  continuous  over  the  tip  of  the  appendix.  I'pon 
the  length  of  this  free  border  depends,  in  a  great  measure,  the  position  of  the 
appendix;  if  long,  the  appendix  appears  straight  or  slightly  curved  ;  while  if  too 
short,  the  appendix  is  drawn  into  a  spiral  or  a  number  of  varying  bends  (Figs. 
86  and  148). 

In  the  infant  the  mesappendix  is  thin  and  transparent,  owing  to  the  absence 
of  fat.  In  the  adult  it  grows  somewhat  thicker  and  more  opaque  and  is  fre- 
quently supplied  with  fat  and  epiploic  appendages.     Sometimes  this  invasion 


MESAPPENDIX.  93 

by  fat  is  so  great  that  the  mesappendix  resembles  a  grape-like  mass  of 
adipose  tissue  (Fig.  113). 

The  free  border  of  the  mesappendix  envelops  the  main  appendical  artery, 
with  its  accompanying  vein,  lymphatics,  and  nerve.  Secondary  branches  pass 
from  these  to  the  appendix,  between  the  two  peritoneal  leaves  of  the  mesen- 
tery. 

Besides  vessels  and  fat,  the  mesappendix  may  also  contain  lymphatic 
glands  along  its  mesenteric  and  cecal  borders.     (See  Chap.  VII,  p.  183.) 

The  extent  of  the  mesenteriolum  along  the  appendix  is  also  a  matter  of 
much  difference  of  opinion. 

Normally,  ('.  e.,  in  about  seventy-five  per  cent,  of  cases,  the  appendix  is 
surrounded  by  a  complete  serous  envelope,  which  adheres  to  it  very  closely  and 
is  continuous  with  its  mesentery.  In  the  remaining  cases  the  appendix  is 
situated  partly  or  entirely  extraperitoneally,  i.  c,  a  portion  of  its  surface  is 
devoid  of  peritoneal  covering.  The  mesappendix  in  normal  cases  goes  all  the 
way  to  the  tip,  or  may  even  extend  slightly  beyond  it,  forming  a  knob-like  pro- 
jection; it,  however,  frequently  appears  to  stop  at  some  distance  from  the  tip, 
extending,  in  some  cases,  according  to  Treves,  Jonesco,  and  others,  only  to 
the  middle  of  the  appendix,  or  to  the  junction  of  the  middle  and  distal  thirds. 
The  artery,  to  the  presence  of  which  the  mesappendix  owes  its  origin,  is  never- 
theless always  to  be  found  extending  to  the  very  tip  of  the  appendix,  though 
along  this  terminal  portion  of  its  course  it  may  not  elevate  the  peritoneum 
sufficiently  to  form  a  definite  fold  or  mesentery.  In  these  cases  the  mesappendix 
seems  to  terminate  at  the  point  where  the  peritoneum  is  no  longer  elevated 
by  the  artery,  a  distance  of  from  1  to  2  cm.  from  the  tip.  Lafforgue  says  this 
occurred  in  seven  per  cent,  of  his  cases. 

A  li  n  ii  r  in  ;i  1  Positions  or  C  o  n  d  i  t  i  o  n  s. — About  twenty- 
five  per  cent. 

(a)  The  mesappendix  may  develop  in  the  place  of  the  ileocolic  fold,  arising 
from  the  anterior  layer  of  the  mesentery  and  descending  in  front  of  the  ileum 
to  the  appendix,  the  ileocecal  fold  in  such  instances  being  attached  to  its  posterior 
instead  of  its  anterior  surface. 

(b)  Or  the  mesappendix  may  develop  from  the  ileocecal  fold,  the  appendical 
vessels  passing  within  it  instead  of  originating  a  separate  fold. 

(r)  Or  the  appendical  artery  may  travel  along  the  posterior  side  of  the 
appendix  near  the  hilum  and  entirely  fail  to  lift  up  the  mesentery  into  the 
form  of  a  fold.  This  condition  has  been  noted  by  Lockwood  and  Rollestox, 
and  accounts  for  the  statement  made  by  some  authors  that  the  mesappendix 
is  sometimes  lacking.  Such  an  appendix  resembles  the  type  met  with  in  the 
brown  howler  monkey  of  Brazil. 

The  absence  of  the  mesappendix  may  also  be  brought  about  in  the  manner 
described  under  "  Position  of  the  Appendix,"  where  the  cecum  by  its  abnormal 


94  ANATOMY. 

distention  gradually  forces  its  way  between  the  two  peritoneal  leaves  of  the 
mesappendix,  which  separate  and  become  appropriated  to  cover  the  cecum. 
This  process  brings  the  appendix  vertically  behind  the  cecum  (Fig.  71,  II,  and 
Fig.  76). 

Among  Lockwood  and  Rolleston's  six  groups  of  positions  of  the  mes- 
appendix, we  find  the  following  of  special  interest. 

The  mesappendix  may  be  spread  on  the  peritoneum  of  the  iliac  fossa,  and, 
either  by  coalescence  or  by  traction  of  the  gubernaculum,  become  more  or  less 
adherent  to  it.  The  posterior  leaf  of  the  mesappendix  is  then  reflected  on  to 
the  floor  of  the  iliac  fossa  at  a  much  lower  level  than  the  normal. 

The  mesappendix  may  be  caught  and  fixed  in  a  subcecal  or  retrocolic  fossa 
(generally  the  internal  retrocolic  fossa),  in  which  instance  the  appendix  tip 
appears  frequently  adherent  to  the  deepest  portion  of  the  fossa.  The  mes- 
appendix may  he  perforated,  and  in  the  hole  thus  produced  a  loop  of  small 
intestine  is  apt  to  pass  and  become  strangulated. 

The  mesappendix  has  been  variously  called  meso-appendix,  tnesenteriolum, 
and  "  posterior  meso-appendix  "  (Clado). 

A  number  of  peritoneal  folds  have  been  described  as  arising  from  the  posterior 
surface  of  the  mesappendix  and  connecting  it  with  neighboring  organs.  Laf- 
POBGUE  states  that  in  five  per  cent,  of  his  cases  a  pelvic  fold  united  the  mes- 
appendix with  the  crural  or  inguinal  arch.  In  about  twenty  per  cent,  of  his 
cases  he  found  also  the  appeiidiculo-ovarian  ligament  of  CLADO,  which  may 
establish  lymphatic  and  vascular  communication  between  the  appendix  and 
ovary.  It  parses  transversely  over  the  iliac  vessels  and  joins  the  broad  liga- 
ment.    This  structure  will  be  more  fully  described  on  page  102. 

The  Origin  of  the  Pericecal  Folds.-  In  the  foregoing  pages  has  been 
given  a  brief  description  of  the  peritoneal  folds,  vascular  and  non-vascu- 
lar, as  they  pass  between  the  colon,  cecum,  ileum,  and  appendix.  The 
nomenclature  is.  as  we  have  seen,  quite  extensive,  ami  the  conception 
of  different  writers  as  to  the  different  structures  varies  to  a  large  ex- 
tent. The  complex  relationship  of  these  structures  becomes  at  once 
very  simple  if  we  return  to  the  earliest  indications  of  the  same  in  the  embryo. 
The  three  folds,  ileocolic,  ileocecal,  and  mesappendix,  in  the  primitive  stage 
appear  as  shown  in  the  first  diagrams  of  Types  I.  H.  and  111.  fig-.  67,  68,  and 
70.  The  primitive  stages  of  Types  II  and  III  appear  to  be  only  slight  variations 
of  that  of  Type  I,  which  develop,  however,  into  very  different  adult  forms. 
We  see  that  the  appendix  does  not  exist  as  such,  but  is  only  visible  as  the  cecal 
pouch  which  is  connected  with  the  terminal  portion  of  the  ileum  by  a  peritoneal 
fold.  This  fold,  the  original  cecal  mesentery,  ultimately  becomes  the  ileocecal 
fold,  and  as  the  appendix  is  nothing  but  the  undeveloped  cecum,  it  might 
well  be  termed  the  real  mesentery  of  the  appendix.  As  it  becomes  supplanted 
in  the  adult  by  the  posterior  fold,  it  appears  here  only  rudimentary. 


DEVELOPMENT    OF    THE    VASCULAR    FOLDS. 
Type   I. 


9.1 


Side  view.  Front  view. 

A,  Primitive  Stage. 


B,   More  Advanced  Stage,  Showing  Growth   of  Posterior  Vascular  System  c. 


C,  Adult  Form. 
Fig.  67. — The  Development  of  the  Vascular  Fojldb.     (Usual  form.) 


96  ANATOMY. 

The  arrangement  of  the  anterior  and  posterior  ileocolic  folds,  the  latter  of 
which  becomes  the  mesappendix,  is  determined  by  the  cecal  1, ranches  of  the 
ileocolic  arteries.  Each  contains  a  vessel  which  causes  the  serous  coat  to  be 
elevated,  and  gives  rise  to  a  definite  serous  fold.  These  two  arterial  branches 
are  seen  in  the  primitive  stages  of  Types  1.  II.  and  III.  In  all  they  are  seen 
to  he  arranged  symmetrically,  passing  in  front  of.  and  behind  the  terminal 
portion  of  the  ileum  and  giving  off  in  their  course  little  t  w  ilt~  to  both  sides  of 
the  cecum.  Their  terminal  branches,  however,  differ  in  the  three  types  to 
some  extent.  The  manner  ni  their  termination  in  relation  to  the  growing 
portion  of  the  cecum  is  of  the  greatest  importance  in  the  ultimate  formation 
of  the  three  folds.  If  the  posterior  branch  supplies  the  growing  tip  of  the 
cecum,  we  have  a-  a  resull  the  Type  I  depicted  in  Fig.  <>7.  which  is  found  in 
an  overwhelming  majority  of  cases.  If  the  anterior  vessel  supplies  the  growing 
tip,  as  seen  in  Type  II.  Fig.  68,  the  conditions  are  reversed;  and  if  the  terminal 
branch  joins  the  middle  fold,  as  shown  in  Type  III.  Fig.  70,  we  have  another 
variety  occasionally  met  with  in  the  adult.  The  two  latter  types  are.  however, 
quite  rare. 

From  these  investigations  it  becomes  obvious  that  the  mesappendix  is 
nothing  hut  one  of  the  two  cecal  folds  in  front  of  and  behind  the  termination 
of  the  ileum.  Whichever  vessel  supplies  the  growing  tip.  develops  with  it, 
gaining  in  length  and  in  complexity  of  terminal  branches,  as  shown  in  Types 
I,  II.  and  III,  B  and  ('.  This  development  of  the  vessels  in  Type  T  lifts  up 
the  peritoneum  of  the  posterior  ileocecal  fold  and  makes  it  dominate  its  an- 
terior fellow  considerably  in  size.  It  thus  becomes  the  permanent  mesentery 
of  the  terminal  portion  of  the  cecum,  the  original  mesentery  (b)  remaining 
behind  in  development. 

The  changes  from  the  fetal  stage  to  the  adult  are  easily  understood  by  an 
examination  of  stages  B  and  ('.  Fig.  67. 

The  mesappendix  (c)  is  seen  to  come  from  behind  the  ileum;  the 
ileocolic  fold  la)  with  its  vessel,  terminates  much  higher  up  than  its  fellow 
(c).  The  middle  fold  (b)  persists  as  the  so-called  "bloodless  fold''  (ileo- 
cecal) (b). 

Except  in  a  very  few  cases,  the  anatomy  of  the  ileocecal  region  is  formed 
according  to  this  principle. 

In  Type  II.  Fig.  68,  the  mesappendix  with  its  vessels  is  seen  to  pass  in 
front  of  the  termination  of  the  ileum,  the  appendical  artery  being  the  terminal 
branch  of  the  anterior  cecal  artery,  while  the  posterior  cecal  artery  (c)  is 
developed  to  no  larger  extent  than  the  anterior  in  the  first  type.  The 
ileocecal  fold  (b)  is  seen  to  pass  behind  the  mesappendix  instead  of  in  front. 
The  first  and  second  diagrams  of  Fig.  68,  A  and  B,  show  that  the  anterior  vascular 
system  predominates  over  the  posterior.  It  supplies  the  growing  tip  of  the 
cecum  and   is  carried   and  develops  with  it  in  a  downward  direction.     This 


DEVELOPMENT  OF  THE  VASCULAR  FOLDS. 

Type    1 1 . 


97 


Side  view. 


Front  view. 


A,   Primitive  Stage. 


B,    More   Advanced  Stage,  Showing   Growth   of  Anterior  Vascular   System   a. 


<'.   Adult    Form. 
Fig.  68. — The  Development  of  the  Vascular  Folds.      (Anterior  Mesappendek .) 


\)S 


ANATOMY. 


In;,  69  Abnormal  Position  of  the  Mesappbndix. 
For  development  of  this  type,  ee  Fig.  68.  The  mesappendix  (a)  is  identical  with  the  ileocolic  fold,  passing 
tn  front  of  the  ileocolic  junction.  The  ileocecal  fold  (b)  is  attached  to  the  posterior  surface  of  the  mesappendix 
and  the  cecum.  (See  small  diagram  in  upper  right-hand  corner.)  An  appendix  of  this  type  generally  baa  the 
pendant  form,  hanging  down  in  the  pelvis  or  lodged  among  coils  of  small  intestine.  (Specimen  from  H.  S.  Weaver, 
Philadelphia.) 


DEVELOPMENT    OF    VASCULAR    FOLDS.  99 

type  is  the  opposite  condition  to  that  shown  in  Fig.  67.  Fig.  C>9  is  an  actual 
case  having  this  arrangement. 

In  Type  III,  Fig.  70,  the  ileocecal  fold  has  become  identical  with  the  mes- 
appendix, i.  <?.,  the  vessels  to  the  appendix  pass  in  a  mesentery  which  arises 
broadly  from  the  free  border  of  the  termination  of  the  ileum,  passing  as  a  trape- 
zoid leaf  to  the  hilum  of  the  appendix.  Either  the  anterior  artery  (a)  or  the 
posterior  (c)  may  develop  into  the  appendical.  In  passing  down  to  the  growing 
tip,  the  artery  passes  in  the  mid-line,  Type  III,  A,  where  it  becomes  identified 
with  the  original  cecal  mesentery,  that  is,  the  ileocecal  fold,  together  with 
which  it  passes  through  its  various  stages  of  development.  This  form  is,  as 
was  said  above,  quite  rare. 

While  a  combination  of  Types  I  and  II,  i.  c,  a  condition  where  both  an- 
terior and  posterior  cecal  arteries  supply  the  glowing  tip  of  the  cecum  and 
develop  with  the  tip  into  two  definite  mesappendices,  has  to  our  knowledge 
not  been  observed  in  the  human  being,  there  are  monkeys  in  which  such  an 
arrangement  is  the  rule.     (See  Fi.us.  lil  and  G2,  copied  after  Treves.) 

Complete  lack  of  a  vascular  mesappendix,  that  is,  a  condition  where  neither 
the  anterior  nor  the  posterior  arterial  branches  lift  up  a  peritoneal  fold,  leaving 
the  rudimentary  middle  fold  as  sole  suspensory  ligament  for  the  appendix,  has 
been  observed,  as  before  mentioned.  The  vessels  course  then  in  the  serous 
layer  of  the  appendix,  along  the  hilum.  According  to  Treves,  such  an 
arrangement  is  met  with  in  the  ceca  of  certain  monkeys.  In  man,  however, 
we  have  never  seen  it. 

Between  these  extreme  types  there  are  many  transition  forms,  the  most 
striking  of  which  are  as  follows: 

A  long  broad  mesappendix,  with  persistent  ileocecal  fold,  giving  the  im- 
pression of  a  double  mesappendix; 

A  short  and  narrow  mesappendix,  the  artery  lifting  up  only  an  insignificant 
peritoneal  fold,  making  the  appendix  appear  as  though  the  distal  portion  were 
without  a  mesentery. 

The  Retrocecal  or  Subcecal  Folds  and  Fossae. — Various  folds  and 
fossa?  have  been  described  as  lying  beneath  the  cecum,  and  therefore 
called  subcecal  or  retrocecal.  They  depend  entirely  for  their  existence 
upon  the  coalescence  or  adhesion  of  the  colon,  cecum,  and  mesentery  to  the 
posterior  abdominal  wall,  and  are  therefore  secondary  in  origin  as  compared 
with  the  three  folds  previously  described.  These  folds  are  simply  eleva- 
tions of  the  peritoneum,  extending  from  the  cecum  to  the  abdominal  parietes. 
They  serve  in  a  measure  to  hold  the  cecum  in  place,  and  have  therefore  been 
called  the  suspensory  ligaments  of  the  cecum.  In  some  cases  the  cecum  never 
becomes  adherent  to  the  posterior  abdominal  wall,  and  we  therefore  find  no 
retrocecal  folds  or  fossa'.  The  folds  in  any  case  exist  only  when  the  parts 
remain  in  situ  within  the  body,  disappearing  almost  entirely  on  removal.  They 
may  develop  at  any  point   behind  the  cecum,  extending  a  varying  distance 


100 


A,    I'nirui  h  6  Stage. 


B,   M'»re  Advanced  Stage,  Showing  Union  of  Posterior  Vascular  System   (c)   with   Middle  Fold  (b). 


i  ,  Adult    Form. 

Fig.  70. — The  Development  of  the  Vascular  Folds.       (Me&appendix  Attached  to  Lower  Border  of 

Ileum.) 


RETROCECAL    FOLDS    AND    FOSS.E.  101 

upward,  hack  of  that  organ  and  down  over  the  floor  of  the  iliac  fossa.  On 
lifting  up  tiit'  cecum,  such  folds  can  always  be  produced,  but  there  are  a  few 
which  seem  to  be  more  constant  and  which  have  been  described  as  more 
or  less  so  by  certain  authors.  Of  course,  any  two  such  folds  enclose  a 
fossa  which  may  extend  to  a  considerable  length  upward,  hack  of  the  cecum, 
and  even  extending  as  high  as  the  colon.  The  appendix  has  frequently  been 
found  lying  curled  up  in  such  a  fossa,  pathological  conditions  of  the  organ 
sometimes  resulting  from  this  position. 

The  number  of  folds  and  their  nomenclature  are  considerable,  and  there 
is  little  unity  concerning  their  description  in  the  literature  of  the  subject. 
We  should  not  render  the  subject  any  clearer  by  quoting  what  different 
authors  have  said.  By  going  back  to  the  primitive  stages  and  studying  the 
development  of  these  folds  and  fossa?,  a  much  better  and  clearer  appreciation 
of  their  topography  will  be  obtained.  Their  classification  will  also  become 
simplified. 

The  posterior  surface  of  the  cecum  and  colon,  i.  e.,  the  embryonic  left  side, 
undergoes  a  fusion  with  the  parietal  peritoneum  during  the  latter  months  of 
fetal  life,  which  may  involve  the  posterior  surface  of  the  entire  mesocolon,  the 
colon,  and  part  of  the  cecum.  This  would  be  a  complete  fusion.  If  the  fusion 
be  incomplete,  a  number  of  pockets  or  fossa?  remain  which  are  accessible  from 
the  general  peritoneal  cavity  from  three  sides:  from  the  left  or  inner  side,  from 
below,  and  from  the  right  or  external  side.  Between  these  fossa?  folds  are 
seen  which  may  be  variable  in  number  and  extent.  The  large  intestine  at  the 
time  of  fusion  represents  a  straight  tube,  to  which  the  cecum  is  attached  in  the 
form  of  a  simple  round  pouch.  The  lateral  and  inferior  line  of  fusion  when 
complete  is,  therefore,  a  comparatively  unbroken  one,  until  the  cecum  and 
colon  begin  to  balloon  out  to  form  the  characteristic  compartments  so  pro- 
nounced in  the  adult.  This  uneven  expansion  lifts  up  the  peritoneum  in  a 
series  of  folds  which  have  been  observed  in  great  variation  and  described  by 
many  authors.  If  the  fusion  was  originally  incomplete,  the  fossa'  are  deep; 
while  in  cases  of  complete  fusion  the  fossa'  are  comparatively  shallow. 

The  most  capacious  and  the  most  constant  of  the  fossa?  is  the  internal  retro- 
colic  (Fig.  66,  3),  also  called  inferior  ileocecal,  which  can  only  be  demonstrated 
by  lifting  up  the  cecum,  appendix,  and  ileum.  It  is  then  seen  as  a  funnel- 
shaped  pocket  extending  in  an  upward  direction  under  the  ileum  and  colon. 
From  the  depth  of  this  fossa  arises  the  posterior  leaf  of  the  mesappendix,  and 
the  entire  appendix  is  oftentimes  found  curled  up  in  this  space,  while  its  tip 
may  point  in  various  directions.  When  the  intestines  are  in  normal  position  it  is 
impossible  to  see  the  appendix  without  lifting  up  the  cecum  and  ileum  so  as 
to  expose  this  internal  retrocolic  fossa. 

The  cecum,  as  a  rule,  is  completely  surrounded  by  peritoneum,  and  on  lift- 
ing it  upward,  the  folds  and  fossa'  which  become  visible  underneath  the  cecum 


102  ANATOMY. 

are  found  to  be  retrocolic  and  nol  retrocecal.  There  arc,  as  a  rule,  two  up- 
liftings  of  the  peritoneum  (Fig.  (><>.  il  and  e),  between  which  is  seen  a  retrocecal 
or,  if  very  deep,  retrocolic  fossa.  We  repeat  thai  both  terms  may  be  correct 
according  to  the  extent  of  the  peritoneal  reflection,  whether  low  and  confined 
to  the  cecum,  or  whether  extending  high  up  under  the  colon. 

II'  the  ileocolic  portion  of  the  intestine  becomes  adherent  comparatively 
high,  the  cecum  will  have  in  sag  downward  a  considerable  distance  in  order 
to  till  the  lower  apex  of  the  iliac  fossa.  The  retrocecal  pocket  or  pockets  are 
then  very  deep  ami  the  folds  exceedingly  well  developed.  The  reverse  condi- 
tion is  found  if  the  ileocolic  region  becomes  adherent  at  a  lower  level.  The 
tip  (if  the  appendix  may  occasionally  lodge  in  this  pocket. 

<  )n  the  right  or  external  side  of  the  colon  there  are  also  one  or  more  folds, 
which  are  seen  at  varying  intervals,  passing  from  the  serous  coat  of  the  ascending 
colon,  as  a  rule,  behind  the  posterior  muscular  hand,  outward  to  the  parietal 
peritoneum.  Traction  on  either  or  both  places  of  attachment  renders  these 
folds  more  conspicuous.  The  pockets  between  the  folds  are,  like  the  others,  of 
varying  depth,  and  it  is  impossible  to  make  any  statement  as  to  their  char- 
acter which  would  he  applicable  to  all  cases.  The  pockets  may  be  entirely  ab- 
sent, and  likewise  the  folds,  while  the  entire  posterior  surf  ace  of  the  colon,  as  well 
as  that  of  the  cecum,  may  be  covered  by  peritoneum.    The  peritoneal  reflection 

is  then  situated  along  the  mesial  border  of  the  colon.  The  reflection  may  be 
found  even  more  toward  the  median  line,  the  colon  possessing  in  this  case  a 
free  mesentery  similar  to  that  of  the  small  intestine.  In  the  two  latter  in- 
stances the  appendix  is  usually  of  the  pendant  type.  The  appendix  may  also 
be  found  in  a  retrocolic  position,  or  in  a  position  curving  around  the  lateral 
border  of  the  colon,  with  its  t i | >  pointing  toward  the  kidney  or  gall-bladder, 
or  adherent  thereto.  If  the  appendix  becomes  adherent  to  the  parietal  ab- 
dominal wall  before  the  colon  and  mesocolon  become  attached,  the  appendix 
will  be  held  in  some  such  position  while  the  cecum  continues  to  descend. 

The  Appendiculo-ovarian  Ligament.-  On  lifting  up  the  appendix  and 
cecum  in  the  female,  it  is  often  possible  to  demonstrate  the  presence  of 
a  thin  peritoneal  fold  passing  from  the  mesappendix  or  the  adjacent  cecal  or 
iliac  serosa  in  a  median  direction  to  the  infundibulo-pelvic  ligament,  also  called 
the  vascular  pedicle  of  the  ovary.  This  fold,  which  can  be  rendered  more 
distinct  by  traction,  is  said  to  carry  blood-vessels  and  lymphatics,  thus  estab- 
lishing a  connection  between  the  vessels  of  the  appendix  and  ovary,  or 
between  the  portal  and  systemic  circulation.  Moreover,  it  is  described  as 
containing  muscle-fibres. 

While  admitting  the  occasional  presence  of  a  peritoneal  fold  passing  in  a 
transverse  direction  from  the  iliac  fossa  to  the  ovarian  vascular  pedicle  on  a 
level  with  the  division  of  the  common  iliac  vessels,  a  fold  which  may  be  found 
to  vary  greatly  in  length  and  height,  we  positively  deny  the  existence  of  any 


APPENDICULO-OVABIAN    LIGAMENT.  103 

considerable  vascular  and  lymphatic  communication  between  the  ovary  and 
the  appendix  by  means  of  this  peritoneal  fold.  The  developments  of  the 
ovary  and  of  the  appendix  take  place  a  great  distance  apart  from  each  other, 
the  ovary  developing  on  the  niesio-ventral  surface  of  the  Wolffian  body,  one 
of  whose  vessels  persists  as  the  ovarian,  while  the  others  disappear.  The 
ovary,  together  with  the  retrograding  Wolffian  body,  descends  into  the  pelvis, 
drawing  the  ovarian  vessels  with  it.  which  thus  become  lodged  in  the  length- 
ening diaphragmatic  ligament  of  the  Wolffian  body.  The  parietal  peritoneum 
completely  covers  all  these  structures.  While  these  changes  have  taken  place, 
the  appendix  has  passed  through  its  various  phases  of  development  quite  inde- 
pendently of  the  ovary,  ft  lies  first  within  the  cord,  and  by  the  time  it  enters 
the  abdominal  cavity  in  the  middle  line  just  beneath  the  stomach,  it  begins 
to  receive  its  vascular  supply,  which  it  carries  with  it  on  its  downward  course. 
The  blood-vessels  of  both  the  ovary  and  the  appendix  are  completely  formed 
before  they  become  neighboring  organs.  The  mesappendix,  as  well  as  the 
mesocolon,  does  not  fuse  with  the  parietal  peritoneum  until  the  fourth  or  fifth 
month  of  intrauterine  life.  If  they  do,  they  are  generally  attached  high  up 
in  the  iliac  fossa.  Any  subsequent  vascular  connection  between  the  two  organs 
must  therefore  remain  confined  to  the  usual  small  amount  of  lymph  and  blood 
capillaries  of  the  parietal  peritoneum.  The  huge  veins  traversing  the  fatty 
capsule  of  the  kidney  which  drain  into  the  renal  or  spermatic  (ovarian)  veins, 
do  not  usually  reach  as  far  down  as  the  appendix;  but  even  if  they  do,  they 
are  found  on  the  other  side  of  the  prerenal  fascia  and  do  not  communicate  with 
the  appendical  vessels. 

The  fusion  of  the  large  intestine  and  mesocolon  with  the  parietal  peritoneum 
is  subject  to  many  individual  variations,  ft  may  be  more  or  less  lacking,  or, 
on  the  other  hand,  quite  complete.  The  peritoneal  folds  established  by  this 
fusion  differ,  therefore,  greatly  in  number  and  position  in  different  subjects, 
as  shown  by  the  varying  topography  of  the  retrocecal  and  retrocolic  folds  and 
fossa'.  The  appendiculo-ovarian  ligament  is  only  one  of  a  large  number  of 
these  more  or  less  irregularly  situated  peritoneal  folds  in  the  region  of  the 
iliac  fossa. 

That  peritoneal  folds  may  contain  veins  of  some  size  is  a  well-known  fact, 
and  most  of  the  folds  in  the  ileocecal  region  are  known  to  have  them.  These 
veins  are  rarely  more  than  0.5  mm.  in  width,  and  through  them  a  small  portion 
of  the  cecal  and  colic  blood  is  carried  toward  the  veins  of  the  posterior  ab- 
dominal wall,  i.  e.,  into  the  ilio-lumbar  or  circumflexa-iliuni  profunda,  and 
occasionally  into  the  spermatic  or  ovarian  veins.  Such  vessels  establish  a 
communication  between  the  portal  and  the  systemic  circulation,  and  in  cases 
of  obstruction  of  the  portal  vein  they  are  apt  to  be  found  much  distended, 
as  is  the  case  with  similar  other  collateral  channels,  known  as  the  veins  of 
Retzius. 

It  has  been  claimed  that  infections  of  the  appendix  are  communicated  to 


104  ANATOMY. 

the  ovary  through  this  ligament,  and  several  writers  have  made  extensive 
studies  on  the  cadaver  to  prove  this  point.  The  various  statements  of  the 
different  authors,  however,  are  noi  in  harmony,  some  even  denying  the  presence 
of  the  ligament  altogether.  It  often  seems  as  though  they  have  not  been 
referring  to  the  same  anatomical  structure.  DuRAND  terms  it  the  ileo-ovarian 
ligament,  and  from  his  description  it  becomes  evident  that  he  lias  been  dis- 
cussing the  vascular  pedicle  of  the  ovary.  Hasse  describes  it  as  the  infundib- 
ulo-pelvic  ligament,  a  term  which  is  also  used  by  HENLE. 

Scih  lt/.k  and  Hasse  speak  of  it  as  terminating  at  the  iliac  vessels,  while 
Valli.x  insists  that   the  ligament  ascends  into  the  lumbar  region. 

Ion  get's  description  is  very  elaborate  but  does  not  differ  materially  from 
that  of  the  others. 

Clado  makes  the  following  statement:  ''In  lifting  the  appendix  it  can  be 
seen  that  it  forms  a  peritoneal  fold  which  separates  from  the  mesappendix  and 
continues  with  the  superior  border  of  the  broad  ligament.  It  is  falciform; 
its  least  elevated  portion  rests  on  the  iliac  vessels  and  varies  from  one  to  two 
centimetres  in  height."  lie  claims  that  it  is  also  found  in  the  male,  although 
much  smaller  in  size.  In  his  description  he  mentions  that  by  means  of  this 
ligament,  lymphatic  connection  is  established  between  the  ovary  and  the 
appendix. 

Contrary  to  this  statement  of  Claud's,  all  of  our  experiments  in  injecting 
the  lymphatics  of  the  appendix,  from  the  periphery  toward  the  centre,  demon- 
strated that  the  lymph  channels  of  the  appendix  pass  inside  the  mesappendix 
toward  the  ileocolic  group  of  glands,  or  through  the  cecum  in  the  same  direction 
ultimately  to  the  same  group.  Not  one  single  lymph  channel  was  seen  to  pass 
in  the  peritoneum  toward  the  ovary. 

Descriptions  of  the  appendiculo-ovarian  ligament  similar  to  that  of  Clado 
have  been  given  by  L.AFFORGUE,  the  latter,  however,  contesting  its  constancy, 
as  he  only  found  it  seventeen  times  in  ninety  female  subjects. 

Durand  gives  it  exceptional  insertions:  (1)  into  the  peritoneum,  enveloping 
the  termination  of  the  ileum.  (2)  sometimes  into  the  cecal  reflection.  AVhile 
the  ligament  seems  with  some  investigators  to  he  an  established  fact,  BARNSBY 
(1898)  not  only  contests  it,  hut  almost  denies  its  existence.  In  127  cadavers 
he  never  found  it.  Ferry,  also,  who  examined  17  cases,  did  not  find  it  in  a 
single  instance.  Poirier  and  Cuneo  likewise  emphatically  state  that  there  is 
no  such  structure  as  the  appendiculo-ovarian  ligament. 

THE  REFLECTION  OF  THE  PERITONEUM. 

While  the  anterior  surface  of  the  large  intestine  and  its  mesentery  are  en- 
tirely covered  by  peritoneum,  the  posterior  surface  becomes  fused  with  the 
peritoneum  of  the  parietal  abdominal  wall.  This  process  begins  about  the 
fourth  month  of  intrauterine  life  and  proceeds  from  the  centre  to  the  periphery. 


TYPES    OF    PERITONEAL    REFLECTION.  105 

It  may  be  extensive;  and  a  considerable  portion  of  the  posterior  surface  of  the 
large  intestine  may  become  adherent,  or  it  may  be  limited  to  a  comparatively 
small  area,  so  that  much  of  the  large  intestine  retains  its  free  mesentery,  in 
which  case  we  find  capacious  pockets  or  fossa-  behind  the  intestine.  The 
lines  which  limit  the  fusion  mark  the  reflection  of  the  peritoneum  from  the 
intestine  over  to  the  parietal  abdominal  wall.  Mewed  from  behind,  the 
portions  of  the  intestine  central  to  these  lines  are  extraperitoneal  surfaces, 
while  those  located  peripherally  are  intraperitoneal. 

The  line  of  peritoneal  reflection  in  the  ileocecal  and  ileocolic  region  is,  as 
might  be  supposed,  subject  to  many  variations.  It  may  be  very  high  ("Fig. 
71,  I),  leaving  cecum,  appendix,  ileum,  and  colon  free  and  movable,  on  a  mesen- 
tery as  long  as  12  cm. ;  or  very  low,  depriving  the  entire  ileocecal  apparatus  of 
a  movable  mesentery  (Fig.  71,  VIII),  and  fixing  it  quite  firmly  in  the  iliac 
fossa. 

Between  these  two  extreme  types,  Figs.  I  and  VIII,  neither  of  which  occurs 
frequently,  there  are  many  transition  forms,  which  place  the  line  of  peritoneal 
reflection  in  different  directions  and  at  various  levels.  It  is  either  longitudinal 
(Fig.  71,  IV),  transverse  (II),  or  oblique  (III),  and  when  studied  in  relation 
with  the  body,  Treves  finds  that  it  lies  usually  between  the  level  of  the  highest 
points  of  the  iliac  crest  and  that  of  the  anterior  superior  iliac  spines.  Its  rela- 
tion to  the  muscles  is  as  follows:  if  oblique  or  transverse,  it  crosses  the  psoas 
and  a  small  portion  of  the  iliacus;  if  longitudinal,  it  may  pass  along  the  outer 
or  inner  margin  of  the  psoas;  and  a  very  high  transverse  line  may  correspond 
to  the  lower  margin  of  the  kidney. 

Developmental  and  pathological  distortions  excepted,  we  find  that  both 
cecum  and  appendix  are  generally  covered  on  all  sides  by  peritoneum:  i.  e.,  the 
line  of  peritoneal  reflection  passes  above  them,  the  average  distance  from  the 
cecal  point,  according  to  Treves,  being  10  cm.  Bardeleben  says  correctly, 
therefore,  that  the  cecum  is,  as  a  rule,  completely  covered  by  peritoneum,  that 
it  is  freely  movable  below  the  ileocecal  junction,  and  that  its  downward  move- 
ment is  hindered  by  its  attachment  to  the  ascending  colon  and  not  by  a  fusion 
with  the  parietal  abdominal  wall.  The  supposition  that  the  cecum  is  partly 
an  extraperitoneal  organ,  and  that  cecal  hernia',  inguinal  or  femoral,  have  no 
peritoneal  sac,  is.  therefore,  erroneous.  In  exceptional  instances,  however, 
such  as  are  represented  in  Type  VIII,  Fig.  71,  a  cecal  hernia  may  take  place 
without  formation  of  a  complete  peritoneal  sac.  Treves  and  others  deny 
that  the  cecum  has  a  mesentery.  Being  on  all  sides  surrounded  by  peritoneum 
and  only  attached  to  the  colon  above,  there  is  indeed  no  mesocecum  proper,  all 
the  cecal  vessels  and  lymphatics  passing  through  the  ileocolic  fold  anteriorly, 
and  along  the  cecal  wall  and  mesappendix  posteriorly.  The  embryonic  cecal 
mesentery  persists  in  the  adult  as  the  ileocecal  fold,  a  rudimentary  structure, 
carrying  only  a  few  insignificant  vessels. 

In  studying  the  eight  diagrams  given  in  Fig.  71.  a  comprehensive  view  may 


106  NWTOMY. 

be  obtained  of  the  types  of  peritoneal  reflection  in  the  ileocolic  region.  All 
pictures  are  posterior  views  of  the  intestine.  These  types  are  not  drawn  with 
reference  to  the  different  positions  the  appendix  may  assume.  Concerning  the 
relation  of  the  appendix  to  the  peritoneal  reflection,  see  Figs.  1-  78. 

Fig.  71.  Ty  pe  1.  Eight  per  rent.  An  entirely  free  colon,  cecum,  and 
ileum,  as  that  shown  in  this  type,  corresponds  to  the  form  found  in  many 
mammalia,  hut  in  man  it  is  met  with  in  only  a  few  instances.  The  cecum  is 
then  apt  to  hang  far  down  into  the  pelvis,  displaying  an  excess  of  develop- 
ment. 

Type  II.  Four  per  cent.  An  almost  transverse  line  of  peritoneal 
reflection  situated  some  distance  above  the  ileocecal  valve.  The  mesappendix 
may  or  may  not  in  such  cases  be  utilized  to  cover  the  large  intestine. 

Ty  pe  III.  Sixteen  per  cent.  The  line  is  oblique  and  still  quite  high, 
much  of  the  colon  being  tier.  The  appendix  is  generally  tucked  away  under 
the  ileocecal  junction. 

Type  I  V.  Ten  per  cent.  The  line  corresponds  to  the  median  border 
of  the  colon.  The  entire  posterior  surface  of  the  colon  is  covered  by  peritoneum, 
while  the  corresponding  surface  of  the  termination  of  the  ileum  is  without 
peritoneal  lining.     The  appendix  hangs  free  below  the  ileocecal  junction. 

Ty  pe  V.  Fight  per  cent.  The  line  of  reflection  has  advanced  over  the 
inner  half  of  the  colon  and  crosses  the  posterior  muscular  hand  at  a  high  level. 
The  posterior  surface  of  the  ileum  is  extraperitoneal,  the  appendix  lying  free. 

Type  VI.  Thirty  per  cent.  This  is  the  most  frequent  type,  almost 
one-third  of  all  cases  showing  such  an  arrangement.  The  next  frequent  types 
are  HI,  TV,  and  VII. 

Type  VI.  The  line  of  reflection  runs  somewhat  obliquely  from  the 
posterior  leaf  of  the  mesappendix,  across  the  lower  portion  of  the  ascending 
colon,  traversing  the  posterior  muscular  hand  about  8  cm.  from  the  cecal 
pouch  and  continuing  upward  close  to  the  lateral  colic  margin.  The  distance 
of  this  line  from  the  lowest  point  of  the  cecum  may  vary  considerably,  pro- 
ducing transition  forms  with  the  other  types.  The  ileum  is  completely  covered 
by  peritoneum  and  the  appendix  frequently  lies  tucked  away  under  it. 

Ty  pe  V  I  I.  Sixteen  per  cent.  The  line  of  reflection  runs  along  the  pos- 
terior muscular  hand  almost  to  the  appendix;  the  median  half  of  the  colon  and 
terminal  portion  of  the  ileum  are  extraperitoneal,  the  appendix  either  hanging 
down  free  or  being  adherent  to  the  extraperitoneal  surface  of  the  cecum  and 
colon. 

Type  VIII.  Eight  per  cent.  The  entire  posterior  surface  of  the  colon 
and  cecum  and  termination  of  the  ileum  are  extraperitoneal',  and  the  line  of  re- 
flection is  almost  identical  with  the  outer  contour  of  the  large  intestine.  The 
appendix  may  again  hang  down  free  or  point  upward  and  be  adherent  to  the 
posterior  surface  of  the  cecum  and  colon,  i.  e.,  be  extraperitoneal  in  position. 

The  question  whether  the  appendix  is  an  intraperitoneal  or  extraperitoneal 


REFLECTION    OF    PERITONEUM. 


107 


Fig  71. — The  Eight  Most  Frequent  Types  of  Peritoneal  Reflection  of  the  Ileocecal  Region. 

The  intestine  is  viewed  from  behind.     The  extraperitoneal  surfaces  are  drawn  darker  in  order  to  differentiate 

them  from  the  smooth  serous  surfaces  of  the  intraperitoneal  portion. 


ins 


ANATOMY. 


organ  is  chiefly  decided  by  the  position  it  assumes  in  relation  to  the  cecum 
ami  colon,  ?'.  c\,  whether  it  he  directed  downward  or  upward.     Or,  in  more  cor- 


I- it;.  72.  (  -.Ion,  cecum,  and 
appendix  are  surrounded  bj  peri 
toneum. 


Fig.  73. — The  middle  portion 
of  the  ascending  colon  is  adherenl 
to  the  parietal  abdominal  wall ;  the 
rest  of  the  colon,  cecum,  and  ap- 
pendix are  Ln1  raperitoneal. 


Fig.  74. — The  entire  ascend- 
ing colon  and  the  base  of  the  ap- 
pendix arc  adherent  along  the 
postei  I'M  abd<  tminal  wall,  while 
the  rest  of  the  appendix  and  the 
cecum  are  intraperitoneal. 


Fig.  75. — The  appendix  is  adherent  to  the  pos- 
terior surface  of  the  colon  as  well  as  to  the  posterior 
abdominal  wall.  i.  e.,  it  is  of  the  extraperitoneal  as- 
cending type. 


Fig.  76. — The  appendix  is  adherent  only  to  the 
posterior  wall  of  the  colon,  but  not  to  the  posterior 
abdominal  wall.  On  turning  the  colon  toward  the 
middle  of  the  body  the  appendix  ia  easily  exposed  to 


rect  expression:  early  fusion  between  the  colon  and  the  posterior  abdominal 
wall  is  apt  to  produce  an  ascending  and  retroperitoneal  appendix,  while  late 


PERITONEAL    COVERING    OF    APPENDIX. 


109 


fusion  brings  about  a  pendant  intraperitoneal  appendix.  (See  "  Position  of 
Appendix."  Chap.  V,  p.  118.) 

Figs.  72  to  78  show  the  seven  most  striking  types  of  intraperitoneal  and 
extraperitoneal  appendices,  the  first  three  figures  giving  the  peritoneal  relation 
of  the  pendant  appendices,  while  the  other  four  illustrate  the  peritoneal  rela- 
tions of  the  ascending  forms. 

Fig.  72.  The  colon  is  not  adherent  at  any  place  and  the  appendix  is  pendant 
and  intraperitoneal.  It  may.  however,  be  drawn  up  on  to  the  cecum  if  the  latter 
be  distended.     This  type  is  an  exceptional  occurrence. 

Fig.  73.     The  colon  is  adherent  between  the  kidnev  and  the  iliac  crest,  but 


■;  : 


Fig.  77. — The  appendix  is  adherent  to  the  pos- 
terior abdominal  wall,  but  not  to  the  colon.  Its  tip 
may  be  adherent  to  the  kidney  or  gall-bladder. 


Fig.  78. — The  appendix  is  intraperitoneal  at  its 
proximal  and  distal  portions,  while  along  its  middle 
portion  it  is  extraperitoneal,  being  adherent  to  the 
colon  and  the  posterior  abdominal  wall. 


the  cecum  and  appendix  are  free  and  intraperitoneal.  This  type  also  is  not 
very  common. 

Fig.  74.  The  colon,  as  far  as  the  root  of  the  appendix,  is  adherent.  The 
cecum  is  sagging  down  anteriorly,  giving  the  appendix  a  posterior  point  of 
origin.  The  appendix  may  be  entirely  covered  by  peritoneum  or  its  proximal 
end  may  be  extraperitoneal.    This  form  with  its  variations  is  the  most  frequent. 

The  next  four  types  illustrate  the  peritoneal  relation  of  the  ascending  ap- 
pendices; all  four  figures  showing  the  cecum  bent  backward  and  upward,  a 
characteristic  common  to  this  class  of  cases. 

Fig.  75  shows  the  appendix  intimately  adherent  both  to  the  colon  and  to 
the  posterior  abdominal  wall,  i.  c,  it  is  entirely  extraperitoneal. 

Fig.  76  gives  the  picture  of  an  appendix  adherent  to  the  colon  but  not  to 
the  posterior  parietes,  the  peritoneum  intervening  between  the  two. 


110  \WTD\IY. 

Fig.  77  is  the  reversed  condition,  viz..  the  appendix  adherent  to  the  posterior 
abdominal  wall,  but  not  to  the  colon. 

Fig.  78  illustrates  finally  an  interesting  condition  occasionally  met  with. 
The  proximal  as  well  as  the  distal  extremities  of  the  appendix  are  intraperitoneal, 
while  the  middle  portion  is  extraperitoneal,  having  fined  with  the  colon  and 
posterior  abdominal  wall. 

Nut  infrequently  an  appendix  is  adherent  in  a  similar  manner  to  the  under 
surface  of  the  ileum  and  its  mesentery. 


THE  INNER  SURFACE  OF  THE  ILEOCECAL  REGION  AND  ITS  VALVES. 

The  mucous  membrane  lining  the  colon  and  cecum  is  arranged  in  folds 
placed  in  a  characteristic  manner.  With  the  intestine  in  a  state  of  contraction 
these  folds  are  very  numerous  ami  describe  a  wavy  course,  resembling  miniature 
intestinal  coils.  Their  main  direction  is  transverse  and  the  wavy  appearance 
is  due  to  the  contracted  circular  muscle-fibres.  With  the  intestine  moderately 
distended,  the  great  majority  of  these  folds  are  smoothed  out.  leaving  but  a 
few  permanent  transverse  folds,  the  so-called  semilunar  plicae  of  the  colon. 
Between  these  the  pouches  of  the  large  intestine  are  seen  to  balloon  out  to  a 
varying  extent.  The  mucous  folds  on  the  inner  surface  of  the  pouches  are 
still  evident ,  though  quite  shallow,  while  the  plicae  gain  in  height  and  stand 
out  sharply,  projecting  from  3  to  S  mm.  into  the  lumen  of  the  intestine. 

The  plica'  of  the  colon  and  cecum  correspond,  as  may  be  supposed,  to  the 
transverse  grooves  seen  on  the  peritoneal  surface,  their  beginning  and  end 
being  marked  by  the  three  longitudinal  muscular  bands.  As  they  extend  from 
one  band  to  another  their  base  is  attached  to  the  inner  surface  of  the  intestine 
for  one-third  of  the  periphery.  However,  some  of  the  larger  plicae  are  seen 
to  be  continuous  with  one  another  over  a  muscular  band.  This  communicating 
portion,  if  present,  is  quite  shallow.  The  portion  of  the  plica  projecting 
into  the  lumen  has  the  form  of  a  narrow  crescent,  the  broadest  part  of  which  is 
at  the  middle  between  the  longitudinal  muscular  bands.  The  deepest  plica' 
consist  of  reduplications  of  all  the  coats  of  the  intestine,  the  musculature  and 
serosa,  however,  extending  only  half-way  into  the  fold.  The  shallower  plicae 
are  composed  only  of  mucosa  and  submucosal  the  outer  coats  do  not  participate 
in  their  formation. 

The  plicae  are  found  at  fairly  regular  intervals  along  the  mucous  surface, 
resembling  shelve-  put  in  a  round  wall.  Their  distance  from  one  another 
varies  from  1.5  to  3.5  cm.:  but  occasionally  they  may  be  still  further  apart, 
especially  in  the  lateral  cecocolic  region. 

In  the  embryo  and  fetus  there  are  no  plicae  except  the  frenulum  of  the  ileo- 
colic valve,  running  around  the  median  half  of  the  large  intestine  and  dividing 
the  cecum  from  the  colon.  Because  this  is  first  to  form,  it  develops  to  greater 
size  than  the  others,  which  do  not  make  their  appearance  until  after  birth, 


VALVES  OF  ILEOCECAL  REGION. 


Ill 


Fig.  79. — The  Valves  of  the  Ileocecal  Kegiox. 
A  portion  of  the  anterior  wall  of  the  large  intestine  has  been  removed  in  order  to  show  the  structures  in  the 
interior.  The  large  transverse  plica  dividing  the  cecum  from  the  colon,  and  called  the  frenulum,  separates  into 
two  lips  which  form  the  ileocecal  valve.  The  upper  of  these  lips  slightly  overhangs  the  lower.  Below  the  valve 
we  see  the  large  expanded  cavity  of  the  cecum.  At  the  lower  median  portion  of  this  lies  the  crescent-shaped 
appendico-cecal  valve.  The  two  small  diagrams  are  sections  of  the  two  valves,  the  up|>er  right-band  picture 
demonstrating  the  construction  of  the  ileocecal  valve,  the  lower  left-hand  picture  that  of  the  appendical  valve. 


112 


\\  VIOMV. 


Fig.  80. — The  Appearance  oj  ruE  Appendical  Orifice  in  a  Case  in  whicb   mi    *  eco-appendical  Anglf. 

Measured  20  Degrees. 
The  valve  (Oerlach's  valve)  is  a  crescent-shaped  ritl^e  of  cecal  mucosa  resting  immediately  upon  the  mucosa 
of  the  appendix.      The  mecham~m   is  such   thai   distention   "f  the  cecum   will  clo-e  the  mouth  of  the  appendix. 
The  valve,  however,  will  not   prevent  the  contents  of  the  appendix  from  pa^-um  hack  into  the  cecum;  i.e.,  it 
has  'lie  same  effect  as  the  ileocecal  valve. 


' 


Fig.  SI. — The  Appfvkanle  op  thb  Appendical  <>kim-*    in   a  Case  in  whicb  rai  Cecc-apfendical  Angle 

Measured  30  Degrees. 

The  cre-ceni--haped  mucous  fold  does  not  completely  close  the  opening  into  the  appendix,  and  further  in  we 
see.  though  indistinctly,  a  second  counterfold  (described  by  Nanningaj.  In  distention  of  the  cecum  these  folds 
will  shut  off  the  entrance  into  the  appt 


APPKXniC.VL    ORIFICE. 


113 


Fig.  82. — The  Appendical  Uhifice  in  Connection  with  a  Ceco-appendical  Angle  of  -42  Degrees. 

Both  Gerlach's  and  Nanninga's  folds  are  well  marked  but  do  not  act  as  valves,  as  slight  pressure  on  the  cecum  will 

cau.se  its  contents  to  pass  into  the  appendix,  and  vice  versa. 


Fig  83. — The  Appendical  Orifice  in  a  Case  in  which  the  Ceco-appeniucal  Angle  Measchkd  60  Degrees. 
Again  the  two  mucous  folds  are  well  developed,  but  do  not  close  the  mouth  of  the  appendix. 


Ml 


\\  \lu\lV. 


when  the  saccular  of  the  colon  begin  to  bulge  out.  The  Frenulum  is  also  pro- 
duced by  a  different  process  than  the  other  plicae,  in  so  far  as  it  owes  its  forma- 
tion to  a  projection  of  the  terminal  portion  of  the  ileum  into  the  lumen  of  t  ho 
large  intestine;  a  beginning  intussusception,  though  of  a  modified  character. 
The  ileum  thus  lifts  up  a  transverse  fold,  which  becomes  a  valve  at  this  junc- 
tion. This  is  the  ileocecal  valve,  surrounding  a  narrow  slit,  whose  direction  is 
transverse.  The  valve  consists  of  an  upper  and  a  lower  lip,  which  join  at 
their  ends  (Fig.  79).  The  upper  lip  is  generally  broader  and  overhanging  the 
lower,  hike  the  other  transverse  folds,  the  frenulum  of  the  ileocecal  valve  is 
semilunar  in  shape,  bul  longer,  extending  over  more  than  one-half  of  the  per- 


nio. 84. — Ceco-Appendical  Angle  oi  60  Degrees. 

Wide  gaping  mouth  of  the  appendix.     Gerlach's  and  Nanninga's  folds  have  almost  disappeared  and  resemble  the 

concentrically  arranged  mucous  folds  of  the  cecum. 


iphery  of  the  intestine.  The  valve  is  not  exactly  in  the  middle  of  the  frenulum, 
but  nearer  its  anterior  portion.  Seen  from  the  peritoneal  surface,  the  frenulum 
and   valve  correspond   to  the  deep  kink  at  the  ileocolic  junction. 

The  terminal  portion  of  the  ileum  curves  around  the  cecum,  making  a  sudden 
turn  shortly  before  the  valve,  and  bringing  the  axis  of  the  lumen  to  stand  at 
right  angles,  or  nearly  so,  to  the  axis  of  the  colon  ascendens.  (See  Fig.  79,  upper 
diagram.) 

Any  pressure  arising  from  within  the  cecum  or  colon  will  serve  to  tighten 
this  valve,  and  contraction  or  tension  of  the  circular  muscle-fihres  in  the 
frenulum  will  have  the  same  effect.  Fig.  79  illustrates  comprehensively  the 
anatomical  structures  producing  this  mechanism. 


VALVK    OF    Al'I'KXDIX. 


n; 


The  mucous  surface  of  the  cecum  is  also  elevated  at  certain  intervals  corre- 
sponding to  the  depressions  between  the  saccular,  most  of  the  folds  being, 
however,  quite  shallow;  only  one  or  two  attaining  the  development  of  the 
colic  plica>.  Their  number  depends  upon  the  length  of  the  cecum  and  the 
degree  of  its  fixation. 

On  opening  the  cecal  pouch  from  above  and  looking  toward  the  appendical 


Fig.  85. — Ceco-appendical  Angle  of  90   Degrees. 

Fetal  type,  showing  tapering  ceco-appendieal  junction.     Gerlach's  and   Nanninga's   folds  are  entirely  absent. 
There  is  no  obstacle  to  the  free  passage  of  intestinal  contents  in  either  direction. 


opening,  the  folds  are  seen  to  be  grouped  more  or  less  concentrically,  the  shortest 
being  around  the  orifice  of  the  appendix,  where  they  may  simulate  a  valve 
(Figs.  79-S6).  If  the  cecum  tapers  gradually  into  the  appendix,  the  folds 
of  the  funnel  may  appeal'  as  double  or  triple  valvular  structures. 

The  most    frequent  arrangement   is  shown  in   Fig.  SO.  where  a   semilunar 
fold   or  reduplication   of  mucous  membrane  is  seen   just  above  the  appendical 


in;  \wm\iY. 

orifice.    This  is  what  Gerlach  *  (1847)  has  described  as  the  valve  of  the  ap- 
pendix. 

This  structure  is.  however,  no1  a  valve  in  the  true  sense  of  the  word,  and 
is  clearly  seen  only  with  the  appendix  coming  off  al  an  acute  angle  from  the 
cecum,  i.  e.,  if  there  is  a  sudden  kink  at  the  appendico-cecal  junction,  the  axis 


Fig.  .so — l.xi  1.1'iiowL  Form   "i     ^.ppendxcal  Orifice  in  a  Case  in  which  the   Appendico-cecal  Angle 

\] i  \-i  1. 1  i.  only   il'  Degrees. 
In  spite  of  the  very  acute  angle  t lie  orifice  was  gaping,  nothing  preventing  the  passage  of  the  contents  in 
either  direction      This  condition  is  due  to  the  presence  of  a  Large  pouch  (a)  opposite  the  crescent-shaped  fold. 

The  pouch  represents  the  Last     acculat I  the  cecum,  especially  large  in  this  case,  and  extending  part  of  the 

way  int .  >  the  appendix. 

of  the  appendix  running  at  less  than  an  angle  of  4.")  degrees  to  the  wall  of  the 
cecal  pouch.  This  angle  varies  according  to  the  different  positions  of  the 
appendix  from  10  degrees  to  90  degrees.     If  the  appendix  has  a  short  mesentery 

and  ascends  for  some  distance  behind  the  ileocecal  junction,  as  is  the  case  in 

♦  This  valve  «a>  accurately  described  by  Gerlach  and  goes  by  his  name,  but  it  was  previ- 
ously noted  and  clearly  described  by  Merling,  I.  1).  Heidelb.,  1836. 


VALVE    OF    APPENDIX.  117 

the  majority  of  instances,  the  smallest  angles  arc  produced  (Figs.  80  and  81). 
A  distention  of  the  cecum  will  then  cause  the  semilunar  fold  to  lay  itself  over 
the  opening  of  the  appendix  and  thus  act  as  a  valve.  Of  course,  muscular 
contraction  plays  an  equally  important  part  in  the  closure  of  the  orifice. 

An  appendix  having  a  wide  mesentery  and  directed  toward  the  iliac  vessels 
usually  forms  an  angle  of  40  degrees  to  60  degrees  with  the  cecal  surface  (Figs. 
82,  83,  and  84).  In  such  cases  the  semilunar  mucous  fold  above  the  orifice 
is,  as  a  rule,  joined  by  asecond  and  smaller  fold  on  the  opposite  side  and  situated 
some  distance  within  the  appendix  (Nanninga).  Both  folds  combined  fre- 
quently do  not  suffice  to  close  the  orifice,  and  a  distention  of  the  cecum  will 
involve  the  appendix. 

In  appendices  of  the  tapering  fetal  type,  the  angle  usually  measures  90 
degrees,  and  while  there  may  he  a  succession  of  shallow  transverse  mucous 
folds  projecting  into  the  lumen,  there  is  no  indication  of  a  valve  (Fig.  85). 
The  axis  of  the  appendix  is  in  direct  linear  continuity  with  the  axis  of  the 
cecum,  and  if  in  such  cases  the  cecum  is  distended,  the  appendix  will  always 
be  distended  with  it. 

There  are  exceptional  cases  where  an  acute  angle  may,  nevertheless,  he 
associated  with  a  wide  and  open  appendical  orifice.  One  of  these  cases  is 
pictured  in  Fig.  86.  At  its  junction  with  the  appendix  the  lateral  cecal  pouch 
forms  a  capacious  sac  (a)  the  presence  of  which  makes  it  impossible  for  the 
semilunar  appendical  valve  to  effectively  close  the  mouth  of  the  appendix. 


CHAPTER   VI. 
ANATOMY. 

THE  POSITION  OF  THE  APPENDIX.     THE  DIMENSIONS  OF  THE  APPENDIX.     THE 

STRUCTURE  OF  THE  APPENDIX.     THE  CONTENTS  OF  THE  APPENDIX. 

OBLITERATION  OF  THE  APPENDIX.     RETROGRESSION. 

POSITION  OF  THE  APPENDIX. 

Point  of  Origin. — The  location  of  the  poinl  of  origin  depends  entirely 
upon  the  topography  of  the  cecum.  According  to  whether  the  cecal  pouch 
is  directed  upward  or  downward,  nut  wan  1  or  inward,  forward  or  backward,  or 
whether  colon  and  cecum  have  rotated  insufficiently  or  too  much  around  their 
long  axis,  the  point  of  origin  of  the  appendix  varies  in  position.  It  may  be 
found  at  almost  any  point  of  the  cecal  pouch,  as  shown  in  Fig.  >>7. 

There  arc  however,  two  main  locations  for  the  point  of  origin,  viz..  I.  behind 
the  cecum,  and  II.  in  front  of,  or  at  the  lower  region  of  the  cecum:  and  it  is 
a  recognized  fact  that  the  development  of  either  of  these  two  positions  is  due 
to  the  influence  of  the  peritoneal  fusion  of  the  mesocolon  with  the  posterior 
abdominal  wall,  whether  early  in  embryonic  life  'cecum  in  subhepatic  position) 
or  late  (cecum  in  iliac  position).  Early  fusion  produces  the  first  type;  late 
fusion  the  second. 

Early  fusion  is  brought  about  by  the  ileum  leaving  the  subhepatic 
region  at  an  early  date,  thus  permitting  the  cecum  to  lodge  at  once  against 
the  prerenal  peritoneum:  the  mesocolon  and  inner  border  of  the  large  intestine 
become  adherent  at  a  high  level  and  the  subsequent  descent  and  expansion 
of  the  cecum  occur  mainly  in  its  lateral  and  anterior  portion.  The  distention 
and  sagging  down  of  the  cecum  in  this  manner  causes  it~  axis  to  he  directed 
median  ward  anddorsally.  Asa  result  the  apex,  ororigin  of  the  appendix,  shifts 
obliquely  upward  and  backward  to  the  left,  i.e.,  toward  the  middle  of  the 
body,  and  the  appendix  appears  hidden  behind  and  mesial  to  the  cecum  with 
it<  proximal  portion  pointing  upward  (Figs.  88,  89,  90,  01.  92,  and  93). 

Late  fusion  is  caused  by  the  ileum  remaining  in  the  subhepatic  position 
between  cecum  and  kidney  during  the  initial  stages  ><\  the  cecal  descent,  pre- 
venting the  two  organs  from  early  becoming  adherent.  When  the  ileum  has 
finally  swung  around  to  the  left  and  the  cecum  and  appendix  come  in  contact 
with  the  parietal  abdominal  wall,  the  descent  has  already  progressed  far  enough 
to  brhi£  the  cecal  pouch  in  apposition  with  the  iliac  fossa.  Peritoneal  fusion 
118 


POINT    OF    ORIGIN    OF    APPENDIX. 


110 


taking  place  at  this  late  stage  will  not  materially  affect  the  subsequent  form 
nf  the  descending  cecal  pouch.  There  is  little  traction  in  a  mesiodorsal  direc- 
tion, ami  the  apex  of  the  pouch — i.  e.,  the  origin  of  the  appendix — will  remain 
near  the  lowest  portion.  As  a  result  the  appendix  is  more  inclined  to  assume 
the  pelvic  position  or  lodge  among  coils  of  small  intestine  i  Fig.  94). 

The  position  first  described — i.e.,  behind  the  cecum — is  that  generally 
met  with,  which  indicates  that  in  the  human  embryo  the  fusion  takes  place  usually 
at  an  early  period,  and  therefore  in  the  majority  of  cases  the  appendix  i<  found 
to  arise  on  the  internal  and  more  or  less  posterior  surface  of  the  cecum,  at  a 
distance  of  from  1  to  4  cm.  below  the  ileocecal  valve.  This  mesioposterior 
position  of  the  point  of  origin  is  found  in  the  overwhelming  majority  of  ca-i s. 


Fig.  87. — Diagram  Showing  the  Various  Places 
on*  the  Surface  of  the  Cecum  from  whi<  h  the 
Appendix  may  take  its  Origin.  The  changes 
in  position  of  the  origin  are  brought  about  by 
the  varying  topography  of  the  cecum. 


Fig.  88. — The  point  of  origin  is  at  (a),  Fig.  87. 
The  specimen  is  from  a  fetus  seven  months  old.  It 
shows  the  appendix  arising  from  the  mesio-anterior 
portion  of  the  cecum  and  pointing  in  an  upward  direc- 
tion, behind  the  me>entery  of  the  ileum. 

The  appendix  is  of  the  tapering  fetal  type,  which 
sometimes  persists  in  the  adult.      (See  Fig.  89.) 


According  to  Treves,  it  occurs  in  ninety  per  cent.  Fig.  87  (point  c)  and  Figs. 
90,  91,  92,  93.  and  97. 

Variations  of  this  position  are  given  in  Figs.  98  and  99.  If  the  cecum 
has  rotated  around  its  axis  so  as  to  render  the  posterior  longitudinal  muscular 
band  visible,  the  origin  of  the  appendix  becomes  shifted  toward  point  d.  Fig. 
98  is  an  example  of  this  form.  If  the  rotation  is  still  more  pronounced,  the 
origin  of  the  appendix  is  on  the  lateral  border,  usually  pretty  high  up  <c).  and 
the  direction  of  the  appendix  is  toward  the  liver  (Fig.  99).  The  ileocolic 
junction  shifts  also  in  a  posterior  direction. 

The  other  points  of  origin,  a,  h.  and  /.  are  found  on  the  anterior  face  or  on 
the  lower  portion  of  the  cecum.  These  are  the  main  variations  of  the  second 
type,  produced  by  late  fusion.  A  long  ami  free  mesocolon  is  generally  asso- 
ciated with  this  type. 

Figs.  88  and  94  show  the  appendix  arising  from  the  mesio-anterior  portion 


L20  INATOMY. 

at  poinl  a,  Fig.  87.     Fig.  88  is  the  typical  tapering  cecum  of  the  fetus,  while 
Fig.  89  shows  the  same  form  persisting  in  the  adult.     Fig.  (••")  illustrates  the 


Fig.  89. — Persistent  Fetal  Ttpe  of  Cecum  and  Appendix  in  an  Adult.     (Specimen  from  H.  S.  Weaver 

OF    PhILADELPHI  \    I 

The  a\i-  of  the  cecum  .stand-  almost  at  ri^ht  am:!e-  to  the  axis  of  the  colon  and  there  is  a  deep  kink  at 
the  ileocolic  junction.  The  cecal  pouch  curve- upward  ami  gradually  tapera  into  the  appendix.  The  latter  is 
directed  upward  behind  the  mesocolon. 

effect  of  a  long  and  free  mesocolon  upon  the  form  of  the  cecum  and  the  point 
of  appendiceal  origin.  The  cecum  does  not  curve  over  to  the  left,  but  extends 
straight  downward  in  the  same  direction  with  the  axis  of  the  colon.     The  pouches. 


POINT    OF    ORIGIN    OF    APPENDIX. 


121 


on  both  sides  of  the  anterior  muscular  band  are  symmetrical  and  the  appendix 
arises  from  the  lowest  point  of  the  cecum.     Fig.  87  (point  b). 


Fig.  90. — The  Appendix  Arises 
from  the  Median-  Portion 
of  the  Cecum  at  Point  (c), 
Fig.  87. 

The  cecum  is  bent  toward 
the  ileum,  and  the  appendix  is 
hidden  behind  the  terminal  por- 
tion of  the  small  intestine. 


Fig.  91. — Appendix  Arising  at 
Point  (c),  Fig.  87. 
The  cecum  describes  t  he  same 
curve  as  shown  in  preceding  figure 
and  its  lateral  pouch  has  attained 
considerable  proportions.  It  is 
often  subdivided  into  several 
smaller  sacculations,  as  shown  in 
this  picture. 


Fig.  92. — Point  of  Appendical 
Origin  at  (c).  Fig.  87. 
The  tapering  cecum  is  bent 
inward  and  upward,  the  appendix 
lying  curled  up  beneath  the  ileo- 
cecal junction. 


Fig.  93. — Point  of  Origin  at  (c).  Fig.  87. 
While  the  lateral  cecal  pouches  are  developed  to 
considerable  extent,  the  median  pouch  is  of  insig- 
nificant size.  In  this  type  the  appendix  arises  very 
near  the  ileocecal  junction.  Fig.  97  shows  the  same 
position  combined  with  abnormal  arrangement  of 
mesappendix  and  vessels. 


Fig.  94. — The  Appendix  Arises  from  the  An- 
terior and  Median  Extremity  of  the  Cbcum. 
Point  (n).  Fig.  S7. 

The  posterior  cecal  pouch  is  visible  beneath  and  to 
the  left  of  the  appendico-cecal  junction. 


Exceptionally  the  appendix  appears  to  arise  from  the  anterior  wall  of  the 
cecum  Fig.  87,   (/').     This  is  likewise  due  to  a  long  mesocolon  which  allows  a 


122 


ANATOMY. 


Fig.  95.  The  Appendix  Arises  prom  the  In- 
ferior Portion*  of  the  Cecum  at  Poini  (6), 
Ik.   ST. 

The  cecal  pouches  have  developed  equally  on 
both  sides  of  the  anterior  muscular  band  and  there  is 
no  curve  ol  the  cecum  in  the  direction  of  the  ileum. 
1 1 !•■  appendix  may  liana:  down  or  be  directed  upward 
behind  the  c<  >wn  in  this  figure.     Tbiscon- 

dition  i-  often  due  to  distention  of  'In*  cecum,  causing 
reparation  of  the  two  leaves  of  the  mesappendix  and, 
■    ■        equence    fixation  of  the  appendix  in  close 
:i  ppi  i  n  i.  .[i  to  i  he  cecal  wall. 


Fig.  itii-     Point  of  Origin    \t  £/),   Fig.  87. 

The  ileocecal  apparatus  has  Failed  to  rotate 
around  its  Long  axis  and  the  appendix  is  found  aris- 
ing from  the  anterior  and  lateral  face  of  the  cecum, 
The  ileum  entei  the  large  intestine  from  the  right 
in  bead  of  the  left,  and  the  appendix  has  retained 
the  fetal  type.  The  arrows  indicate  the  mannei  of 
rotation,  which  would  bring  the  parts  in  normal  re- 
hit  i<  hi  with  t  he  iliac  fo      ' 


Fig.  97.— Abnormal  Position  of  the  Appendix  and  Abnormal  Arrangement  of  its  Blood-supply. 
The  point  of  origin  is  at  the   ileocecal  junction    (r).  Fig.  87,  anil  the  mesappendix  is  attached  to  the  lateral 
cecal  pouch.     The  ileocecal  fold  is   incomplete,  as  it  i-    uol    attached  to  the   cecum.     The  blood-supply  of  the 
appendix  comes  through  the  ileocolic  fold  and  p:i<>hs  over  the  anterior  surface  of  the  cecum  before  entering  the 
mesappendix.      (.T.  M.  T.  Finney's  case.) 


POINT  OF  ORIGIN  OF  APPENDIX. 


123 


degree  of  rotation  or  torsion  of  the  whole  cecum,  bringing  the  origin  of  the  ap- 
pendix more  toward  the  anterior  side  of  the  cecum.  The  ileocecal  valve  is  in 
such  instances  found  on  the  posterior  lateral  portion  of  the  large  intestine 
(Fig.  96). 

The  point  of  origin  of  the  appendix  on  the  cecum  has  considerable  influence 
on  pathological  conditions.  In  connection  with  this  we  may  distinguish  again 
the  two  main  positions  above  described;  I,  the  retrocecal,  and  II,  the  prececal 
positions.  While  the  latter  would  mean  danger  to  the  patient  in  case  of  disease 
of  the  appendix,  the  former  would  signify  comparative  safety. 


Fig.  98. — Point  of  Origin  at  Point  (d).  Fig.  87. 
The  colon  and  cecum  have  failed  to  rotate  around 
their  lone  axis  and  as  a  consequence  the  posterior 
longitudinal  muscular  band  is  rendered  visible  lateral 
to  the  anterior,  and  the  pointof  origin  of  the  appen- 
dix has  shifted  toward  the  posterior  surface  of  the 
cecum.  The  arrows  indicate  the  rotation  necessary 
for  the  reestablishment  of  the  normal  topography  of 
the  ileocecal  apparatus. 


Fig.  99. — Point  of  Origin  at  (a),  Fig.  87. 
The  ileocecal  apparatus  has  failed  to  rotate  as 
indicated  by  the  arrows.  Both  muscular  bands  are 
vi-il>le  from  the  front  and  the  appendix  is  seen  to 
arise  from  the  outer  posterior  surface  of  the  cecum. 
Such  appendices  often  show  the  fetal  tapering  form 
and  are  generally  directed  upward. 


If  the  point  of  origin  is  retrocecal,  points  c,  '/,  and  e,  Fig.  87,  it  may  or  may 
not  be  an  extraperitoneal  organ,  according  to  whether  the  level  of  the  peritoneal 
reflection  is  above  or  below  the  appendix.  If  it  is  above,  the  appendix  usually 
occupies  a  peritoneal  pocket,  a  condition  generally  favorable  lor  the  prompt 
isolation  of  an  abscess  by  means  of  adhesions;  and  if  the  peritoneal  reflection 
is  below,  the  result  is  an  extraperitoneal  appendix,  a  perforation  of  which 
would  drain  into  the  subperitoneal  tissue  of  the  iliac  fossa,  whence  it  might 
spread  in  several  directions. 

If  the  appendix  occupies  the  anterior  face  of  tin1  cecum,  i.  e.,  if  it  is  prececal, 


124  ANATOMY. 

points  a,  b.  and  /',  Fig.  87,  it  is  then  situated  within  the  peritoneal  cavity,  into 
which  a  perforation  of  the  appendix  might  open. 

Position,  General  Considerations.  -The  appendix,  if  not  hidden  behind 
the  cecum,  is  almost  always  covered  by  loop- of  small  intestine  lying  anterior 
to  it.  When  it  occupies  the  iliac  fossa,  it  is  in  close  relation  with  the  psoas 
muscle  ami  occasionally  with  the  iliacus,  running  either  parallel  to  the  muscle- 
fibres,  or  lying  obliquely  or  transversely  across  them. 

If   the   mesappendix   is  short,    i.  e.,   if  the   posterior  leaf  of  the   peritoneum 

is  reflected  over  the  posterior  abdominal  wall  at  a  lower  level  than  usual. the 
appendix  may  come  into  closer  relationship  with  the  neighboring  structures. 
It  may  be  situated  entirely  behind  the  peritoneum,  between  the  latter  and  the 
pelvic  fascia  and  close  to  the  psoas  and  iliacus  muscles,  or  againsl  the  iliac 
vessels  and  pelvic  wall.  In  some  cases,  the  entire  posterior  leaf  of  the  mes- 
appendix fuses  with  the  parietal  peritoneum,  and  the  appendiceal  vessels  repose 
directly  on  the  posterior  abdominal  wall. 

Robinson  states  that  in  cases  where  the  appendix  is  found  resting  against 
the  psoas  muscle,  there  is  a  decided  tendency  to  the  formation  of  peritoneal 
adhesions.  He  claims  that  the  powerful  contractions  of  this  muscle  and  perhaps 
of  the  iliacus  irritate  the  appendix.  Irritation  produces  adhesions,  which  in 
turn  cause  bends,  kinks,  and  obstructions,  thus  impairing  the  circulation  and 
peristalsis,  and  rendering  the  appendix  incapable  of  emptying  itself. 

In  cases  of  undescended  cecum  the  ileum  generally  crosses  the  psoas  to 
meet  the  high  cecum,  and  ROBINSON  claims  that  there  are  invariably  peritoneal 
adhesions  tying  the  ileum  to  the  psoas.  Such  a  case  is  pictured  in  Fig.  109. 
In  his  statistics  RoBiNSON  says  that  the  appendix  was  found  resting  on  the 
psoas  in  forty-six  per  cent,  of  the  male  and  in  twenty  per  cent,  of  the  female 
subjects  he  examined.  Over  four-fifths  of  such  appendices  showed  adhesions. 
The  reason  for  the  preponderance  of  this  position  and  condition  in  the  male 
is  the  narrowness  of  the  male  pelvis  and  the  greater  size  and  strength  of  the 
psoas  in  the  male  as  compared  with  the  female,  where  the  pelvis  is  capacious 
and  the  psoas  less  developed.  Robinson  gives  the  frequency  of  the  pelvic 
position  of  the  appendix  as  forty-eight  per  cent,  in  the  female  and  thirty-seven 
per  cent,  in  the  male.  Only  one-fourth  of  such  appendices  showed  adhesions. 
These  data  seem  to  throw  some  light  on  the  question  why  appendicitis  occurs 
more  frequently  in  the  male  than  in  the  female  (8:1). 

There  is  a  definite  relationship  between  the  consistency  of  the  appendix 
and  the  position  it  occupies.  The  appendix  is  usually  quite  flexible,  this  quality 
diminishing,  however,  with  age.  As  a  rule,  it  is  but  slightly  curved,  and  if 
short,  6  cm.  or  less,  it  may  appear  as  an  almost  straight  tube.  The  same  effect 
is  obtained  by  rigidity  of  the  appendix.  Longer  appendices,  however,  are 
frequently  bent  back  upon  themselves  or  drawn  up  by  the  shortness  of  their 
mesentery  into  various  bizarre  forms,  a  figure-8  or  a  spiral.  If  the  mesappendix 
is  sufficiently  long,  or  if  the  tension  acting  on  the  appendix  by  its  mesentery, 


MOBILITY    OF    APPKXDIX. 


125 


drawing  it  up  into  various  bends  and  sinuosities,  could  be  removed  by  gently 

untwisting  the  mesentery,  the  appendix  would  then  be  seen  to  form  a  fairly 
regular  curve  with  its  concavity  turned  toward  the  cecum;  this  curve  carries 
the  appendix  upward  behind  that  organ,  usually  continuing  the  curve  formed 
by  the  anterior  muscular  band  of  the  cecum. 


Fig.  100. — Diagrams  Showing  thk  Changes  in  the  Topography  of  the  Ileocecal  At-paratcs  due  to  Dis- 
tention of  thk  Colon  in  Casks  of  Non-adherent  ce<  t  iff. 
The  left  section  shows  the  large  intestine  in  normal  state  of  distention,  while  the  right  section  illiterates 
it  in  extreme  state  of  expansion.  The  upper  portion  of  t lie  colon  being  anchored  posteriorly  by  adhesions  and 
being  unable  to  expand  in  the  direction  of  the  liver,  causes  'In-  lower  portion  with  the  cecum  ami  appendix  in 
swing  in  an  anterior  and  median  direction,   '-'..  in  the  direction  of  least   resistance. 


A  long  appendix  with  a  long  mesentery  may  possess  considerable  freedom 

of  motion,  and  it  is  probable  that  it  assumes  different  positions  during  the 
day.  Changes  in  the  position  of  the  body,  whether  erect  or  reclining,  and  the 
different  degrees  of  distention  of  the  adjacent  intestine,  may  contribute  to 
alter  the  topography  of  the  ileoceco-appendical  apparatus.      See  Fig.  100.) 


126  ANATOMY. 

We  sec  therefore  thai  the  direction  and  course  which  the  appendix  takes 
arc  regulated  by  its  length  and  consistency,  and  by  the  mobilit}  given  toil  by 
its  mesentery.  The  tip  may  point  in  almost  any  direction.  The  relative 
frequency  <>t'  the  main  directions  lias  been  given  as  follows: 

Horizontal  toward  promontory,  or  pointing  lat- 
erally    32  per  cent. 

Oblique,  toward  spleen Ill         " 

Ascending :; ! 

1  (escending  LM         " 

loo 

V\g.  101  pictures  more  in  detail  the  various  directions  in  which  an  appendix 
may  point.     These  are.  in  order  of  their  relative  frequency 

1  i  Into  pelvis. 

'_' i  Along  iliac  vessels. 

(3)  To  promontory  of  sacrum, 

i  1 1  Behind  cecum. 

(5)  Under  ileum. 

(Hi  Lateral  to  cecum. 

(7)  Into  iliac  fossa. 

(8)  Among  coils  of  small  intestine. 

(!')    Mesial    to   cecum   over   ileum. 

To  these  should  he  added  the  large  number  of  appendices  which  are  tucked 
away  behind  the  ileocecal  junction  and  of  which  no  direction  can  he  given 
owing  to  the  fact  that  they  are  bent  hack  upon  themselves  without  assuming 
any  distinct  direction.     This  class  is  more  frequent  than  any  other  (Fig.  101). 

Occasionally  an  otherwise  straight  appendix  is  sharply  bent  upon  itself 
near  its  extremity,  forming  a  species  of  hook.  Kinks  or  bends  may,  however, 
form  a!  any  point  along  the  appendix,  being  caused  by  adhesions  to  the  perito- 
neal lining  of  the  abdominal  cavity  or  abdominal  organs,  or  from  one  portion 
of  the  appendix  to  another.      (Fig.  Its.) 

These  different  bends  anil  twists  and  accompanying  firm  adhesions  may 
give  rise  to  strangulation  of  the  intestine,  should  the  appendix  become  adherent 
to  one  of  its  loops.  As,  however,  the  kinked  appendix  is  generally  found  in 
a  retrocecal  position,  such  occurrences  are  fortunately  rare. 

The  literature  on  the  subject  of  positions  of  the  appendix  is  full  of  the  most 
elaborate  statistics;  hut  as  they  make  unprofitable  and  difficult  reading,  they 
have  been  largely  omitted  and  only  the  average  of  the  combined  results  is 
given. 

Most  Frequent  Positions  of   the  Appendix. —The  normal  position  of  the 


MOST    FREQUENT    POSITION'    OF    APPENDIX. 


127 


ileocecal  apparatus  is  in  the  right  iliac  fossa,  the  cecum  occupying  the  triangular 
space  between  the  iliac  vessels  and  Poupart's  ligament.  The  terminal  portion 
of  the  ileum  ascends  obliquely  and  crosses  the  iliac  vessels  about  midway  be- 
tween the  promontory  and  Poupart's  ligament  (Fig.  102). 

In  the  fetus  the  appendix  is,  as  a  rule,  curled  up  at  the  posterior  and  inferior 
aspect  of  the  cecum.  While  in  the  adult  it  is  often  found  lying  below  or  even 
to  the  right  of  the  cecum,  its  most  usual  position  is  along  the  internal  or  median 
border  of  the  organ,    being  often  partially  concealed  behind  the  terminal  por- 


.ibf  hind    Ktiinv 


mesial     ic  cecum  over  ileum 

-intler 


i  n  1 1  i  a  c    f  0  S 


long    iliac  vessels 


Fig.  101. — Diagram  Showing  the  Various  Direction's  in  which  an  Appendix  may  Point. 


tion  of  the  ileum  and  its  mesentery,  to  which  it  is  not  infrequently  adherent. 
If  the  appendix  is  short,  its  tip  will  point  obliquely  upward  in  the  direction 
of  the  spleen  or  the  left  hypochondriac  region.  If  long,  it  may  be  doubled 
back  upon  itself.  It  is  then  that  we  find  it  lying  on  the  psoas  muscle  parallel 
with  its  fibres,  or  crossing  them  in  various  directions,  or  also  reposing  on  the 
iliac  vessels.  Appendices  in  these  positions,  i.  c,  hidden  behind  the  ileocecal 
junction,  are  found  in  about  forty  per  cent,  of  the  cases  (Figs.  '.•().  91,  92,  and 
101). 

The  second  most  frequent  position  of  the  appendix  is  ascending  vertically 


128 


\\  \  II  l\!1  . 


behind  <>r  lateral  to  the  cecum  and  ascending  colon,  more  or  less  attached  to 
the  dorsal  wall  of  the  large  intestine,  and  being  cither  straighl  or  curved  at 
its  extremity  (Figs.  98,  '.»!»,  ami  nil).  It  is  tumid  to  occur  in  from  twenty- 
five  in  thirty  per  cent,  of  the  cases,  and  is  usually  associated  with  the  absence 
of  a  well-formed  mesappendix.  This  position  may  beaccounted  For, asTREVES 
explains,  by  the  abnormal  growth  of  the  cecum,  which,  as  it  enlarges  within 
its  passive  peritoneum,  draws  for  its  covering  from  the  mesentery  of  the  ileum 
and  appendix.  The  two  leaves  of  the  mesappendix  become  unfolded,  lessening 
in    width.     The   disappearance    is    lirst    noticeable    near    the    runt    or    proximal 


Fig.  102. — The  Normal  Position  of  the  Ileocecal  Apparatus. 
The  appendix  is  usually  not  visible  until  the  eeeum  is  lifteil  out  of  the  iliac  Fo  aa. 


end  "1  the  appendix,  drawing  this  portion  close  to  the  posterior  surface  of 
the  cecum.  The  further  distention  of  the  cecum  ami  unfolding  of  the  mes- 
appendix to  cover  it,  cause  the  complete  disappearance  of  the  latter  and  the 
vertical  position  of  the  appendix  along  the  posterior  surface  of  the  cecum  and 
colon.  The  bends  of  the  appendix  are  generally  straightened  out  during  this 
process  (Figs.  95  and  76).  If.  in  addition,  the  colon  becomes  adherent  to  the 
abdominal  parietes.  the  result  is  an  extraperitoneal  position  of  the  appendix, 
which  lies  embedded  in  cellular  tissue  (Fig.  7.")).  The  vertical  position  behind 
the  cecum  may  also  be  produced  by  the  formation  of  early  adhesions  between 


RETROCECAL    POSITION    OF    APPENDIX. 


129 


the  appendix  and  the  organs  lying  posterior  to  the  cecum  in  its  descent,  the 

tip  being  held  adherent  in  the  neighborhood  of  the  kidney,  liver,  or  gall-bladder, 
and  as  a  consequence  of  the  cecal  descent  the  appendix  assumes  a  vertical 
position  behind  the  colon.  Later,  there  may  be  a  fusion  and  disappearance 
of  some  of  the  adjacent  layers  of  peritoneum  covering  the  appendix  and  the 
cecum,  and  the  two  become  partly  or  completely  adherent  to  the  posterior 
abdominal  wall.  This  vertical  position  between  the  cecum  and  psoas  muscle 
may  subject  the  appendix  to  an  abnormal  degree  of  friction  during  contrac- 


;  'P^^f 


Fig.  103. — Diagram  Showing  the  Posi- 
tions of  Moderate  Displacement 
of  the  Appendix,  viz.,  it  is  Still 
Found  in  the  Right  Lower  Quad- 
rant of  the  Abdominal  Cavity. 


Fig.  104. — Diagram  showing  the  excursions  possible  to  an  ileo- 
cecal apparatus  with  a  longand  movable  mesentery,  the  fixed  point 
being  indicated  by  (X).  The  cecum  and  appendix  in  such  cases 
may  be  found  in  any  of  the  four  positions  (a),  (b),  (c),  and  (d),  as 
well  as  at  intermediate  points.  It  may  likewise  occupy  a  ventral 
position  and  lodge  in  an  umbilical  hernia.  (Autopsy,  January  16, 
1902.) 


tion  of  the  muscle,  hence  the  more  frequent  occurrence  of  appendicitis  in  a|>- 
pendices  lying  in  this  position. 

In  both  the  first  as  well  as  the  second  position,  the  tip  of  the  appendix,  or 
occasionally  the  whole  organ,  may  lie  in  a  pocket  or  subcecal  fossa,  formed 
by  folds  of  peritoneum.  These  fossa*  are  found  in  a  great  many  cases  and 
their  position  and  depth  are  very  variable.  If  situated  in  an  available  position, 
any  one  of  them  may  contain  the  appendix.  The  appendix  may  be  curled 
up  inside  such  a  pocket,  or  its  tip  may  be  kinked  in  the  angle  of  the  pocket 
9 


l;;o 


AN  \To\IY. 


(Figs.  203,  257),  in  which  case  adhesions  arc  generally  found  to  be  the  cause, 
or,  again,  it  may  lie  perfectly  straight.  A  case  lias  been  cited  where  the  tip 
was  adherent  to  the  under  layer  of  the  mesentery  of  the  ileum,  forming  a  loop 
in  which  a  coil  of  bowel  might  have  become  strangulated. 

Tlie  third  most  common  position  of  the  appendix  is  the  pelvic,  which  occurs 
in  about  twenty-five  per  cent,  of  the  cases  (Figs.  93,  94,  101,  and  102).  This 
may  be  caused  by  a  low  position  of  the  cecum,  a  long  mesentery  allowing  it 
tn  shift  toward  the  median  line  of  the  body  or  even  sag  into  the  pelvic  cavity. 
Or  the  mesappendix  may  be  of  sufficient  extent  to  permit   the  descent  of  a 


Fig.  IOo. — The  ileocecal  apparatus  being  fixed  in  a  position  it  occupied  during  the  eighth  or  ninth  week 
of  embryonic  life,  the  position  of  the  cecum  is  in  the  epigastric  region  and  the  large  intestine  shows  increased  tor- 
tuo  ity. 


long  appendix  over  the  right  superior  strait  and  into  the  pelvic  cavity.  Here 
it  may  come  into  contact  with  the  ovary  or  tube,  in  some  cases  with  the  uterus, 
rectum,  or  bladder.  Robinson  has  found  the  pelvic  position  to  be  less  fre- 
quent in  male  subjects  than  in  female.  As  was  pointed  out  before,  the  reason 
for  this  may  be  found  in  the  fact  that  the  male  pelvis  is  narrower,  and  the 
psoas  muscle  presents  a  larger  surface  than  in  the  female. 

Abnormal  Positions. — Many  abnormal  posit  inns  of  the  cecum  and 
appendix  have  been  observed  by  different  authors.  It  has  been  seen  in  very 
widely  different  portions  of  the  abdominal  cavity;  in  fact,  there  is  no  region 
from  liver  to  pelvic  floor  where  the  appendix  may  not  be  found.     These  abnormal 


MODERATE    DISPLACEMENT. 


131 


positions  are  due  to  two  causes;  I,  an  abnormally  long  and  free  mesentery,  and 
II,  arrested  fetal  development. 

Moderate  Displacement. — If  the  ileocecal  apparatus  still  remains  in  the 
right  lower  quadrant  of  the  abdominal  cavity,  we  have  to  deal  with  a  moderate 
displacement.  Fig.  103  shows  the  main  variations  of  cecal  topography  inside 
this  area. 

While  (a)  is  the  normal  position, 

(b)  represents  a  shifting  of  the  cecum  over  the  iliac  vessels  and  pelvic 
position  of  the  appendix,  due  to  a  lengthened  mesocolon; 


Fig.  106. — The  cecum  has  descended  from  the  epigastric  region  without  swinging  over  to  the  right  side. 
All  the  large  intestine  is  coiled  up  in  the  left  side  while  the  right  side  is  occupied  solely  by  small  intestine. 
Treitz'e  fossa  duodenojejunal  does  Dot  exist,  the  duodenum  and  jejunum  forming  merely  a  number  of  convolu- 
tions.     (After  Huntington.) 


(c)  is  the  same  condition  still  further  accentuated;  the  sagging  down  of 
the  cecum  causes  the  appendix  to  point  obliquely  upward; 

(d)  shows  the  extreme  form  due  to  the  swinging  of  the  cecum  in  a  median 
direction.  The  pouch  points  upward  and  the  appendix  lies  on  top 
of  it; 

(e)  and  (f)  are  examples  of  the  moderate  forms  of  incomplete  descent  of 
the  cecum.  The  appendix  in  such  instances  is  generally  pointing  in  an 
upward  direction  behind  the  cecum. 

Considerable    Displacement. — Appendix    and    cecum    outside    right     lower 
abdominal  quadrant. 


132 


\\  \  nun  . 


I.  A  l>  n  o  r  in  a  1  Positions  Due  t  •>  a  I.  o  c  g  M  e  s  e  n  t  c  r  y  . — 
Abnormal  positions  of  the  cecum  and  appendix  due  in  a  free  and  movable 
mesocolon  are  comparatively  frequent.  A  long  appendix  with  a  well-developed 
mesappendix  may  extend  across  the  median  line  in  front  of  the  sacrum  and 
the  ilium,  the  tip  coming  in  contact  with  the  lefl  pelvic  wall  or  left  psoas  muscle. 
The  appendix  has  also  been  found  lying  anterior  in  the  middle  lumbar  vertebrae, 
in-  found  floating  in  the  abdominal  cavity  among  foils  of  the  small  intestine. 
Such  appendices  have  been  seen  to  become  adherent  to  the  anterior  abdominal 
wall.     A  long  mesocolon  may  permit  a  complete  shifting  of  the  large  intestine 


In-..  107. — The  cecum  has  become  arrested  in  i  he  subhepatic  position,  a  place  it  occupies  in  an  embryo  of 

ten  weeks.       It    is    in  close  contact   with  the    gall-bladder  all-1  the  liver.       The  ascending  Colon  'hies  not   e\i-t  and 

ih.-  transverse  colon  appear-  ol  exceptional  lenirth  and  is  curved.     The  appendix  is  pendant,  but  may  assume 

many  different  positions.     The  termination  of  the  ileum  runs  upward,  and  the  right    iliac  fossa  is  occupied  by 
ol  small  intestine. 


to  the  left  side  of  the  body,  the  cecum  and  appendix  forming  adhesions  in  this 
region  and  becoming  fixed  (Berry).  A  long  mesentery  may  also  cause  the 
entire  ileocecal  apparatus  to  slide  over  the  iliac  vessels  and  lodge  in  the  pelvis, 
where  the  appendix  may  come  in  contact  with  or  become  adherent  to  any 
of  the  pelvic  organs.  Or  the  apex  of  the  cecum,  bearing  the  appendix  with  it, 
mav  he  turned  upward  and  toward  the  anterior  abdominal  wall,  in  which  case 
it  may  lie  in  front  of  the  transverse  colon.  Fig.  104  illustrates  the  excursions 
possible  to  such  a  movable  ileocecal  apparatus.  It  is  evident  that  in  such 
cases  the  appendix  is  apt  to  he  located  in  inguinal,  femoral,  and  umbilical 
hernia-. 


ARRESTED   FETAL    DEVELOPMENT.  133 

Finally  tumors  of  abdominal  and  pelvic  origin  have  been  known  to  change 
the  position  of  the  appendix. 

II.  Arrested  Fetal  Develop  m  ent  . — During  the  embryonic 
rotation  of  the  intestine  the  cecum  and  appendix  may  become  fixed  at  any 
point  along  their  course.  As  examples  of  this,  the  cecum  lias  been  found  in 
the  left  hypochondriac  region,  the  appendix  resting  on  or  near  the  spleen  or 
below  the  stomach,  the  ascending  and  transverse  colon  being  undeveloped. 
The  large  intestine  is  then  usually  coiled  up  in  the  left  half  of  the  abdominal 
cavity.  In  Fig.  105  is  shown  such  a  condition.  The  cecum  with  pendant 
appendix  has  remained  in  precisely  the  same  position  which  it  occupied  between 


Fig.  108. — The  cecum  arrested  in  subhepatic  position  and  turned  upward,  bringing  the  appendix  in  direct 
contact  with  the  under  surface  of  the  liver.  The  terminal  portion  of  the  ileum  runs  in  an  upward  direction 
and  there  are  loops  of  small  intestine  between  it  and  the  kidney. 

the  eighth  and  ninth  weeks  of  embryonic  life.  The  cecum  and  appendix  have 
also  been  found  in  an  umbilical  hernia,  held  there  by  adhesions  due  to  inrlani- 
mation  during  embryonic  life  (seventh  to  eighth  week).  Lockwood  mentions 
a  case  where  all  the  large  intestine  was  coiled  in  the  left  lumbar  region 
and  left  iliac  fossa,  held  there  by  reflection  of  the  peritoneum,  while  the  small 
intestine  filled  the  right  side  of  the  body. 

The  cecum  may  also  descend  directly  from  the  sub-stomachal  position  without 
swinging  over  to  the  right  side.  (See  Fig.  106.)  Duodenum,  jejunum,  and 
ileum  fill  the  right  half  of  the  abdomen,  while  the  ascending  colon  is  situated 
to  the  left  of  the  middle  line.  The  usual  rotation  of  the  colon  and  cecum  around 
their  long  axis  has  not  occurred,  and  as  a  consequence  the  posterior  longitudinal 


134 


ANATOMY. 


muscular   band    is   seen    in    front.      The   direction    of    the   appendix    is    also 
reversed. 

If  the  cecum  has  progressed  somewhat  further  before  it  becomes  adherent, 
it  is  found  in  the  right  hypochondriac  region.  Such  a  position  corresponds 
to  the  cecal  topography  of  a  ten-weeks-uld  embryo.  The  appendix  may  then 
occupy  various  positions  in  relation  to  the  liver,  gall-bladder,  kidney,  or  duo- 
denum, to  any  of  which  organs  it  may  become  adherent.  bit's.  Hi7.  ION.  and 
in1.)  arc  examples  of  such  abnormalities.  Between  the  subhepatic  and  the 
normal  iliac  positions  are  several  intermediary  locations  in  which  the  ileocecal 


Fig  109  rbe  cecum  in  subhepatic  position  and  pointing  laterally.  The  appendix  arising  from  it*  jjo. 
tenor  and  lateral  extremity  curves  upward,  its  tip  resting  between  gall-bladder  and  colon.  The  terminal  portion 
of  the  ileum  runs  straight  upward  ju-t  lateral  to  the  cle  and  is  adherent  to  the  po  terior  abdominal 

wall  for  a  distance  of   Hi  em.     The  ileocolic  valve  is  situated  just  in  front    of  the  lower  pole  of  the  kidney. 
(Autopsy,  -'005.     cf.     Age  fifty-five.) 


apparatus  may  become  permanently  fixed.  These  have  been  already  described 
as  moderate  displacement  and  pictured  in  Fig.  103. 

According  to  Robinson,  undescended  ceca  occur  in  three  per  cent,  of  female 
and  seven  per  cent,  of  male  subjects,  the  non-descenl  ranging  between  7  and 
13  cm.  above  the  iliac  fossa.  The  favorite  lodging-place  of  an  undescended 
cecum  seems  to  be  the  region  of  the  right  kidney.  The  appendix  of  an  un- 
descended cecum  has  a  tendency  to  preserve  the  fetal  type. 

An  undescended  cecum  is  frequently  associated  with  an  undescended  testis 
or  ovary.  A  band  of  peritoneum  has  been  seen  connecting  the  sexual  gland 
with  the  mesentery  of  the  ileum  near  its  junction  with  the  cecum. 

In  cases  of  situs  transversus  all  the  organ-  are  reversed  and   the  appendix 


MISPLACED    APPENDICES. 


135 


lies  in  the  left  iliac  fossa,  bearing  otherwise  perfectly  normal  relations  to  the 
reversed  cecum  and  ileum  (Fig.  110). 

Misplaced  and  Supernumerary  Appendices. — In  regard  to  misplaced  and 
supernumerary  appendices,  most  of  these  can  be  accounted  for  on  other  grounds. 
In  a  number  of  cases  appendices  have  been  reported  as  arising  from  the  ileum, 
at  various  distances  from  the  ileocecal  valve.  Without  wishing  to  criticize 
these  statements,  it  seems  more  probable  that  these  authors  have  seen  and 
described  Meckel's  diverticulum,  i.  e.,  the  remains  of  the  vitelline  duct  of  the 
embryo.     It   is  also   possible  that  one  of  the  epiploic  appendages  which  are 


Fig.   110. — Transposition  of  the  Viscera. 
The  cecum  occupies  the  left  iliac  fossa  and  the  ileum  enters  from  the  right.     The  appendix  is  of  the  pendant 
type.     The  arrangement  of  the  mesappendix,  its  blood-supply,  as  well  a~  the  position  of  the  ileocecal  fold,  are 
normal  except  that  they  are  reversed.      (Autopsy.  1849.      J.     January  16.  1902.1 

found   at    intervals  along  the  intestine  may  have  been  mistaken  at  times  for 
an  atropine  appendix. 


DIMENSIONS  OF  THE  APPENDIX. 

The  average  length  of  the  appendix  has  been  variously  estimated  by  different 
authors  as  from  8  to  11.5  cm.,  the  mean  of  these  being  9.2  cm.  The  most 
reliable  observations,  however,  and  those  based  upon  the  largest  number  of 
cases,  result  in  a  lower  figure,  and  we  agree  with  Ribhert,  Berry,  and  others 
in  placing  it  at  about  8.3  cm.,  or  between  3  and  31  inches.    Extremely  short 


L36  ANATOMY. 

appendices  have  been  described  from  time  to  time  by  various  observers — 
Ferguson  found  three  which  were  1 12  mm.  long;  others  have  noted  appendices 
of  1  cm.;  while  Bryant  mentions  one  which  measured  only  i>  mm.,  and  Eunt- 

[NGTON    one   of   •")   nun.     Smaller   than    this   none   have   been    reported.     Short 

appendices  arc  more  frequently  obliterated  than  those  of  normal  or  excessive 
length.  Cases  of  complete  absence  of  the  appendix  have  been  described,  but 
it  is  to  be  doubted  that  such  observations  have  always  been  accurate,  as  the 

appendix  can  be  obliterated  and  withered  to  a  narrow  fibrous  cord  adherent 
to  the  wall  of  the  cecum,  and  as  such  easily  escape  notice  ( Fig.  193).  We  have 
been  able  to  demonstrate  such  a  case,  which  had  been  pronounced  as  an  in- 
stance of  total  absence  of  the  appendix.     Nevertheless  there  are  a  few  authentic 

cases  of  complete  absence  of  the  appendix  (ZUCKERKANDL,  BRYANT,  and  EuNT- 
[NGTON).  EuNTINGTON's  first  case  showed  a  rounded  globular  cecum  with 
longitudinal  muscular  hands  converging  to  the  lowest  point  of  the  pouch.  There 
was  no  scar  or  other  evidence  of  operative  removal  or  of  pathological  process. 
His  second  case  had  a  cecum  turned  upward  and  to  the  left,  terminating  in 
a  sharp  point  to  which  several  lobes  of  epiploic  fat  were  attached.  Hrvr- 
[NGTON's  explanation  of  such  forms  is   plausible.      He  assumes  "that    in   these 

cases  the  embryonic  portion  of  the  cecal  bud  was  developed  just  sufficiently 
to  yield  the  required  adult  pouch  with  nothing  to  spare,  so  to  speak,  which 
could  remain  rudimentary  in  the  form  of  an  appendix." 

Robinson  mentions  a  case  (female  subject)  where  not  only  the  appendix 
hut  also  the  cecum  were  congenitally  absent. 

From  the  minimum  of  5  nun.  appendices  range  in  length  up  to  24  cm.  (9£ 
inches)  or  more.  The  longest  appendix  on  record,  to  our  knowledge,  is  one 
presented  by  !•'.  Grauer  of  New  York  to  the  Northwestern  .Med.  and  Surg. 
Soc.   in   1890.     It   measured    12;   inches  in   length  (33  cm.  I. 

Abnormally  long  appendices  have  been  found  by  Lenzmann  (22  cm.), 
LUSCHKA  (23  cm.),  LAFPORGUE  (21  cm.).  One  of  our  specimens,  which  we 
owe  to  the  courtesy  of  J.  I).  BLAKE,  measured  21  cm.  in  length  (Fig.  299). 
Another  long  appendix  is  pictured  in  Fig.   111. 

The  growth  of  the  appendix  is  irregular,  uncertain,  and  apparently  not 
influenced  by  the  development  of  the  main  intestinal  tube.  MECKEL  gives  the 
length  of  the  appendix  in  relation  to  the  entire  alimentary  canal  as  follows: 

In  the  new-born 1-71 

At   fifty  years  of  age 1-115 

In  fetal  life  the  length  of  the  appendix  relative  to  that  of  the  rest  of  the 
intestine  is  greater  than  in  the  adult.  The  length  is  proportional  to  the  age 
of  the  infant,  though  not  in  the  same  degree.  According  to  RlBBERT,  the 
average  length  of  the  appendix  in  the  new-born  is  3f  cm.  The  adult  body  is 
about   three  times  the  length  of  the  new-born,  and  taking  the   length   of   the 


LENGTH    OF    APPENDIX. 


137 


adult  appendix  as  between  9  and  10  cm.,  the  average  given  by  many  authors, 
it  becomes  evident  that  the  appendix  grows  approximately  in  the  same  pro- 
portion as  the  body.  The  greatest  length  is  attained  between  the  tenth  and 
thirtieth  years,  when  the  average  reaches  as  high  as  9^  cm.  Bryant  and 
other  observers  state  that  the  greatest  length  is  reached  between  the  twentieth 
and  fortieth  years.  From  this  time  on,  the  appendix  decreases  in  length,  the 
average  being  8|  cm.  at  sixty  years  of  age,  a  change  due  to  retrogression. 
As  may  be  supposed,   many  deviations   from   the  above-stated   rules  are 


Flo.  111. — An  Appendix  Measuring  21.5  cm.  (8i  inches)  in  Length.     Specimen  from  H.  S.  Weaver,  or 

Philadelphia. 
Along  the  free  border  and  running  obliquely  across  the   proximal  third   are   reduplications   of   peritoneum 
containing  fat.      These  folds  are  often  seen,  especially  along  the  free  border,  and  if  they  carry  isolated  clusters 
of  fat  they  appear  lobulated,  resembling  the  epiploic  appendages  of  the  mesappendix.      (See  Fig.   113.) 


found.  The  appendix  may  attain  its  full  length  much  earlier  in  life.  Treves 
found  an  appendix  of  12  cm.  in  a  child  of  three  years;  Ribbert  one  the  same 
length  in  a  child  of  five  years. 

While  it  is  a  general  rule  that  the  length  of  the  appendix  decreases  with 
advance  in  years,  nevertheless  some  of  the  longest  appendices  occur  in  old 
people,  showing  that  retrogression  does  not  always  take  place 

Fawcett  and  BlancHFORD  found  from  the  measurement  of  350  subjects, 
male  and  female,  that  the  average  length  of  the  male  appendix  is  1  cm.  greater 
than  that  of  the  female.     Robinson  gives  the  difference  as  6  mm.;  he  also 


L38  ANATOMY. 

states  that  extremely  l«>n«r  appendices  are  more  apl  to  be  from  male  subjects. 
According  to  Dock,  the  average  length  in  negroes  is  greater  than  in  whites. 
There  seems  to  be  a  certain  relation  between  the  length  of  the  appendix 

and  that  of  the  cecum.     When  the  appendix  is  long,  the  cecum  is  somewhat 
shortened. 

The  wid  tli  of  the  appendix  is  much  more  constant  and  less  liable 
to  fluctuation.  It  is  usually  described  a-  about  that  of  a  goose-quill.  Fer- 
i.i  son  gives  the  diameter  as  thai  of  a  No.  '.i  catheter,  English  scale.  The  average 
diameters  of  the  appendix  as  given  by  various  author-  are  as  follows: 

1  leaver                3  to  5  mm. 

Dock 5  mm. 

Lafforgue  4  to  <i  mm. 

Bryant      1(1  cases :    6  mm. 

<  iaston about  ti  mm. 

Luschka  7  mm. 

Vallee  (82  cases)     .  8  mm. 

Appendices  measuring  1  cm.  and  l..">  cm.  in  width  have  been  found.  Treves 
describes  one  of  a  male  subject,  age  thirty-seven  years,  which  was  to  cm.  long 
and  1.25  cm.  broad.    This  width  is  to  be  considered  abnormally  large. 

Bryant  has  found  that  the  average  width  of  the  male  appendix  is  2.5  mm. 
greater  than  that  of  the  female.  We  think  that  this  is  excessive.  The  relative 
width  of  the  appendix  to  that  of  the  large  intestine  changes  with  age.  In  the 
new-horn  it  is  about  1  to  4;  in  the  adult  it  averages  about  1  to  8. 

The  diameter  of  the  lumen  changes  according  to  the  contents  of  the  canal. 
whether  gaseous,  liquid,  or  solid.  It  is  usually  of  about  equal  size  through- 
out, with  the  exception  of  a  slight  dilatation  at  the  tip:  while  in  those  cases 
where  the  cecum  has  retained  the  fetal  type,  the  proximal  end  of  the  appendix 
is  funnel-shaped,  and  therefore  possesses  a  greater  lumen.  There  is.  however, 
usually  a  narrowing  of  the  lumen  at  the  neck,  caused  by  the  usual  acute  angle 
at  which  the  appendix  arises  from  the  cecum.  The  mucous  membrane  may 
elevate  itself  around  the  cut  ranee  into  the  lumen  of  the  appendix  in  a  manner 
very  much  resembling  a  valve. 

The  diameter  of  the  lumen  varies  from  1  to  3  mm.,  the  calibre  not  being  in 
proportion  to  the  length  of  the  appendix. 

There  is  also  no  constant  relation  between  the  width  of  the  appendix  and 
the  diameter  of  its  lumen,  except  that  appendices  of  infants  and  young  indi- 
viduals have  generally  a  wider  lumen  than  those  of  older  persons.  The  diminu- 
tion i<  due  to  a  considerable  increase  in  the  thickness  of  the  submucosa  as  age 
advance-. 

According  to  Vallee,  "the  volume  of  the  appendix  is  not  constant.  It 
usually  broadens  out  at   the  cecal  extremity,  becoming  progressively  smaller 


STRUCTURE    OF   APPENDIX.  139 

toward  the  tip.  where  it  again  swells  out,  terminating  in  an  olive  or  club-shajied 
enlargement."  These  two  dilatations  at  the  two  ends  he  considers  normal. 
It  is,  however,  probable  that  the  distal  club-shaped  enlargement  is  the  usual 
sign  of  beginning  obliteration. 

"In  one  case,  an  anomaly,  the  appendix  presented  a  contraction  at  a  point 
15  mm.  from  the  tip.  The  appendix  was  only  5  mm.  thick  at  this  point;  9 
mm.  thick  at  its  origin.  This  shrinkage  was  not  due  to  atrophy  of  the  coat>. 
The  organ  remained  easily  permeable  and  contained  a  serous  liquid  produced 
bv  the  mucosa." 


THE  STRUCTURE  OF  THE  APPENDIX. 

In  the  present  section  the  different  coats  constituting  the  appendix  will 
be  described  in  succession,  first  as  to  their  macroscopic  appearance,  and  then, 
briefly,  as  t<>  tin'  histological  structure.  It  is  impossible  to  give  a  description 
of  the  gross  anatomy  of  the  appendix  suitable  to  all  cases,  as  the  number  of 
variations  is  so  great;  and  as  regards  the  histology  of  this  variable  structure  is 
concerned,  there  are  almost  as  many  variations  as  in  its  anatomical  form. 

The  appendix  is  a  worm-like  appendage  attached  to.  and  continuous  with 
the  lower  portion  of  the  cecum.  Like  the  rest  of  the  intestine,  it  is  enveloped 
in  a  peritoneal  coat,  which  is  continuous  over  its  mesentery.  Since  the  appendix 
develops  out  of  the  fetal  cecum,  it  is  but  natural  that  its  structure,  both  macro- 
scopic and  microscopic,  should  closely  resemble  that  of  the  adjacent  large 
intestine. 

As  in  the  cecum,  the  different  coats  beginning  with  the  outside,  are  arranged 
as  follows: 

(1)  Peritoneal  or  serous  coat. 

(2)  Longitudinal  muscular  coat. 

(3)  Circular  muscular  coat. 

(4)  Submucosa. 

(5)  Mucosa. 

Transverse  sections  through  the  normal  vermiform  appendix  after  hardening 
are  usually  5  or  6  nun.  in  diameter.  The  lumen  which  occupies  the  centre 
may  be  a  mere  slit  in  the  shape  of  the  letter  T  or  of  the  letter  H.  or  irregular. 
Various  shapes  may  be  met  with  in  sections  through  different  parts  of  the 
same  appendix.  The  thickness  of  the  coats  of  the  appendix  varies  from  1  to 
2\  mm.  Of  this  the  peritoneal  and  muscular  coats  compose  about  one-third, 
the  rest  being  submucosa  and  mucosa  (Fig.  112). 

The  Peritoneum. — The  serous  coat  with  its  peritoneal  surface  is  about 
0.1  mm.  in  thickness  and  is  closely  attached  to  the  appendix,  rendering  its 
surface  smooth  and  glistening.  It  is  transparent  and  permits  the  outer  mus- 
cular coat  with  its  vessels  to  shine  through,  the  color  of  the  appendix  being,  there- 


-,♦0; 


<9F% 


a. 


s? 


. 


r    K« 


Fig.  1 12. — Section  through  a  Normal  Appendix,  25  Times  Magnified. 
The  different  layers  from  without  in,  are  i  1 1  The  serous  coat,  consisting  of  a  simple  layer  of  flat  endothelial 
cells,  the  serous,  and  the  subserous  tissue,  containing  t he  superficial  vessels;  (2)  the  longitudinal  muscu- 
lar coat  whose  bundles  are  seen  in  cro  »  tion;  (3)  the  circular  muscular  coat;  (4i  the  submucosa,  traversed 
by  many  vessels  and  supplied  with  a  varying  amount  of  fat  ;  (5)  the  mucosa,  consisting  of  a  surface  epithelium, 
dipping  down  into  the  glands  of  Lieberkuhn,  a  tunica  propria,  situated  between  the  glands,  and  a  muscularis 
mucosa  i  not  distinguishable),  situated  between  the  mucosa  and  the  submucosa.  Between  the  crypts  of  Lieber- 
kuhn and  the  submucosa.  extending  partly  into  the  latter,  are  seen  five  lymph  follicles.  In  this  particular  section 
they  do  not  reach  the  surface.  Their  germinal  centre  stains  more  faintly  than  the  periphery.  The  lumen  of  the 
appendix  contains  mucus,  disintegrating  cells,  and  fecal  matter.  At  the  lower  portion  of  the  section  is  seen 
the  mesappendix  with  its  vessels.  The  spaces  between  the  vessels  are  occupied  by  connective  tissue  containing 
a  considerable  amount  of  fat. 
140 


jAMaonaA    •  • ' 

- 
n\   'nit   j>rmlA 
rfoirfw  lo  >in  >ilqub  ii 

i    x!T 

.qij  -.ili  liiyu  .nun  J  ' 


Fig.    113. — The    Ileocecal    Region   of   a    Woman    Possessing    an    Abnormal 

Amount  of  Fat. 
The  accumulation  in  the  mesappendix  gives  rise  to  the  formation  of  an 
unusual  number  of  large  epiploic  appendages.  Along  the  free  margin  of  the 
appendix  are  folds  or  duplications  of  peritoneum  filled  with  fat.  some  of  which 
are  pedunculated.  The  lumen  of  the  appendix  decreased  from  2  mm.  at  the  cecal 
extremity  to  0.1  mm.  near  the  tip.      (Autopsy,  February  G,  1902.) 


COATS    OF    APPENDIX.  141 

fore,  due  mainly  to  the  deeper  structures  and  their  blood-supply  and  not  to 
the  surface  coat,  which  contains  comparatively  few  vessels.  The  large  vessels 
visible  on  the  surface  of  the  appendix  are  situated  below  the  serous  coat,  between 
it  and  the  longitudinal  muscular  coat.  Along  the  free  margin  of  the  appendix, 
opposite  the  hilum,  the  peritoneum  is  frequently  lifted  up  in  the  form  of  a 
fold  from  one  to  three  or  more  millimetres  in  height,  and  extending  for  a  variable 
distance  along  the  appendix  (Fig.  111).  It  may  be  found  at  the  proximal,  as 
well  as  the  distal  portion  of  the  appendix.  Its  width  varies  according  to  the 
amount  of  fat  present  between  the  layers  of  serosa,  which  may  be  very  con- 
siderable in  stout  persons.  The  free  border  of  this  fold  is  not  always  continuous 
but  often  appears  lobulated,  in  which  instances  the  individual  portions  are 
pedunculated,  resembling  closely  the  epiploic  appendages  of  the  large  intestine. 
The  mesappendix  in  such  cases  generally  shows  similar  masses  of  pedunculated 
fat  (Fig.  113).  The  peritoneum  of  the  mesappendix  does  not  lie  as  firmly 
against  the  underlying  structures  as  in  the  appendix,  for  which  reason  we  find 
it  forming  a  great  number  of  delicate  folds,  more  numerous  at  the  hilum  than 
elsewhere,  lying  approximately  at  right  angles  to  the  appendix.  On  tension 
they  can  be  smoothed  out,  unless  they  are  carriers  of  fat.  The  entire  mes- 
appendix contains  a  varying  amount  of  fat  grouped  between  the  vascular  loops. 
This  is  of  greater  thickness  near  the  appendix.  It  may,  however,  be  so  small 
in  amount  that  it  escapes  notice. 

The  Histological  Structure  of  the  Peritoneum  (Fig. 
112). — The  peritoneum  consists  of  a  simple  layer  of  flat,  polygonal,  endothelial 
cells,  resting  upon  a  delicate  subperitoneal  layer,  which  is  made  up  of  loose 
fibres  and  elastic  tissue,  and  connects  the  peritoneum  with  the  underlying 
structures.  This  subperitoneal  tissue  bears  within  its  meshes  a  variable  amount 
of  fat  and  contains  the  superficial  blood-vessels,  lymphatics,  and  nerves. 

The  Longitudinal  Muscular  Coat  (Fig.  112). — The  three  longitudinal 
muscular  hands  of  the  large  intestine  converge  at  the  cecum  and  form  the 
longitudinal  muscular  coat  of  the  appendix.  The  cecum  possesses  a  longi- 
tudinal muscle  over  its  entire  surface,  but  with  the  exception  of  the  above- 
mentioned  bands,  it  is  much  more  sparsely  developed  than  in  the  appendix. 
The  combined  width  of  the  three  muscular  bands  in  the  adult  is  slightly  more 
than  the  circumference  of  the  appendix.  The  expansion  of  the  cecum  and 
large  intestine  takes  place  between  the  three  muscular  bands,  leaving  a  few- 
longitudinal  fibres  to  cover  the  pouches.  The  thickness  of  the  longitudinal 
muscular  coat  of  the  appendix  varies  in  different  individuals  from  0.2  to  0.3 
mm.  It  is  not  of  uniform  thickness  throughout  the  entire  appendix,  and  in 
any  one  section  it  is  often  seen  to  vary  considerably  at  different  points  around 
the  circumference.  Some  authors  state  that  the  longitudinal  muscular  coal 
becomes  thinner  near  the  tip  of  the  appendix,  but  with  the  exception  of  the 
muscular  hiatus  where  the  blood-vessels  penetrate,  we  have  not  found  it  to 
diminish   appreciably   in   thickness.     The   longitudinal   coat    contains   a   large 


142 


ANATOMY. 


number  of  capillaries  lying  parallel  to  the  fibres  with  shorl  anastomosing  branches 
running  at  right  angles  to  them.  The  collecting  vessels  pass  in  both  an  out- 
ward and  an  inward  direction  (Fig.  120). 

The  Circular  Muscular  Coat  (Fig.  112). — The  circular  muscular  coats 
of  the  cecum  and  appendix  arc  also  continuous.  The  thickness  of  iliis  coal 
is  more  uniform  than  thai  of  the  longitudinal  muscular  coat;  and  it  is 
usually  broader  than  the  latter,  measuring  from  0.2  to  ().">  nun.  in  width. 
Its  bundles  of  fibres  arc  interlaced  at  the  tip  to  form  a  cupola.  Its  blood- 
supply  follows  the  direction  of  the  fibres,  the  larger  vessels  connecting  with 


Fig.   114. — A  Longitudinal  Section  through  the  Distal  Portion  of  a  Normal  Appendix  and  its  Mes- 

entkrioi.im.  Magnified  5  Ti\tt.s, 
In  the  centre  is  the  mucous  membrane,  showing  the  characteristic  folds  and  the  apices  of  the  follicle  pro- 
truding from  Bhallow  depressions  in  the  mucosa.  The  rest  of  the  BUrface  is  studded  with  the  minute  orifices 
of  the  glands  of  Lieberkuhn.  Along  the  hilutn  the  muscular  coats  are  perforated  at  certain  intervals  to  permit 
the  entrance  of  the  vessels  into  the  submucosa.  The  most  distal  perforation  or  "hiatus"  is  at  t he  tip.  admitting 
the  terminal  branch  of  the  appendical  artery  ami  Berving  as  an  exit  for  the  returning  vein  and  Lymph  channel. 
The  terminal  branch  lies  not  infrequently  in  a  little  projecting  peritoneal  fold  filled  with  fat,  appearing  like  a 
knob  on  the  tip  of  the  appendix.  A  few  strands  of  muscle  and  connective  tissue,  as  well  a-  lymphatics  and  nerves, 
accompany  the  vessels  through  the  hiatus. 


those  in  the  submucosa  ami  those  between  the  muscular  layers  (Fig.  120). 
Both  muscular  coats  are  perforated  at  various  points  to  permit  of  the  entrance 
and  exit  nf  the  nerves,  Mm  id-vessels,  and  lymphatics.  Such  a  perforation  is 
called  a  muscular  hiatus,  and  they  are  found  in  varying  numbers  along  the 
mesenteric  border  nf  the  appendix.  The  last  hiatus  is  generally  found  at  the 
tip  (Fig.  H4)  and  it  is  considered  by  some  writers  as  the  cause  of  the  weakness 
nf  the  appendix  at  this  point.  The  number  of  these  perforations  varies  accord- 
ing to  the  number  of  large  vascular  branches  at  the  hilum.  A  long  appendix 
has  therefore  generally  more  such  perforations  than  a  short  one.  The  vessels 
perforating  the  muscle  are  enveloped  by  a  special  fibrous  sheet,  which  is  strength- 


SUBMUCOSA.  1  l.'i 

ened  by  muscle  fibres  coming  from  the  muscular  coats  of  the  appendix.  In 
stripping  the  inner  coats  of  the  appendix  out  of  their  muscular  envelopment 

these  vessels  are  generally  torn  out  of  the  submucosa,  permitting  the  mucous 
membrane  to  protrude  through  the  resulting  perforations.  Each  hiatus  is 
marked  in  such  a  specimen  by  a  little  hernia  of  the  mucous  membrane,  espe- 
cially if  the  appendix  is  distended  (Fig.  299).  If  the  vessels  tear  out  of  the 
muscular  coats,  they  appear  as  delicate  projections  on  the  submucosa  of  the 
stripped  out  specimen  (Fig.  298). 

Concerning  the  stripping  of  the  appendix  out  of  its  muscular 
sheath,  so  frequently  practised  in  operations,  a  few  remarks  may  be  of  value. 
Each  coat  can  be  separated  from  its  adjoining  layer  at  any  point,  but  there  are 
two  places  where  such  a  division  or  stripping  out  is  effected  with  greater  ease 
than  elsewhere.  One  of  these  is  within  the  fibres  of  the  circular  muscular  coat. 
near  the  periphery.  The  sheath  which  is  stripped  off,  will  then  consist  of  the 
serosa,  the  outer  muscular  coat,  and  a  few  fibres  of  the  circular  coat.  The  second 
place  where  the  stripping  out  is  effected  with  ease  is  between  the  circular  coat 
and  the  submucosa.  As  at  this  region  there  are  numerous  blood-vessels  and 
lymph  channels  forming  a  rich  network,  the  layers  of  the  appendix  are  here 
more  loosely  connected.  It  depends  largely  upon  the  depth  at  which  the 
operator  starts  to  strip.  If  he  begin  in  the  circular  coat,  the  rest  of  the 
appendix  strips  out  within  that  coat.  If  he  reaches  the  submucosa,  the  divi- 
sion takes  place  between  it  and  the  muscular  layers. 

The  muscular  layers  of  the  intestine  are  composed  of  smooth  muscle  fibres. 
Their  spindle-shaped  protoplasm  is  of  considerable  length  as  compared  with 
their  small,  elongated  nucleus.  A  section  of  muscle  parallel  to  the  fibres  will, 
therefore,  show  more  nuclei  than  a  section  taken  at  right  angles,  where  many 
of  the  fibres  would  be  cut  to  either  side  of  the  nucleus  (Fig.  112). 

The  Submucosa. — In  contradistinction  to  the  other  layers  of  the  appen- 
dix, which  are  of  more  or  less  constant  thickness,  the  submucosa  varies 
greatly  in  different  individuals.  The  thinnest  submucosa  is  0.2  mm.  in  width, 
the  thickest  measures  0.8  mm.  or  more.  While  the  outer  surface  of  the  sub- 
mucosa is  round  like  that  of  a  cylinder,  its  inner  surface  follows  the  corrugated 
course  of  the  mucous  membrane.  The  submucosa  is  of  a  lighter  color  than  the 
muscular  coats,  and  later  in  life  it  undergoes  fibrous  changes,  becoming  harder, 
bluish  white,  and  glistening.  It  is  this  layer  which  gains  most  in  thickness 
during  the  process  of  obliteration.  It  may  increase  to  two  or  even  four  times 
its  original  size.  The  mucous  membrane  disappears  and  is  replaced  by  fibrous 
tissue  which  i-  continuous  with  that  of  the  submucosa.  Within  the  submucosa 
are  numerous  vessels,  some  of  the  largest  ones  of  the  appendix  being  found 
in  this  layer  (Fig.  120).  The  spaces  between  the  meshes  of  the  fibrous  con- 
nective tissue  framework  of  the  appendix  are  filled  with  a  variable  amount 
of  fat. 

Microscopically,   the  submucosa  consists  of  loose,  wavy  strands  of  fibrous 


Ill  \\  \TO.MY. 

and  elastic  tissue  which  forms  a  framework  for  the  blood  and  lymph  vessels 
and  nerves.  In  the  interspaces  arc  fat  globules.  If  obliteration  takes  place, 
the  connective  tissue  increases  in  density,  compressing  the  vessels,  which firsl 
decrease  in  calibre  and  subsequently  disappear,  the  process  beginning  with 
the  inner  layers  of  the  submucosa  and  at  the  distal  end  of  the  appendix. 

The  Mucosa. — The  mucosa  is  bound  to  the  submucosa  by  the  vestiges 
of  a  muscularis  mucosae.  This  consists  of  a  narrow  layer  of  non-striped  muscle 
fibres  which  cannot  lie  demonstrated  by  dissection.  Sometimes  it  is  not  visible 
under  the  microscope.  If  present,  it  is  lined  on  either  side  by  a  network  of 
lymphatics  belonging  to  the  deep  system  (Fig.   IK)). 

The  mucosa,  or  the  innermost  layer  of  the  appendix,  in  its  normal  state 
presents  an  irregularly  folded  appearance,  the  folds  running  parallel  with  the 
longitudinal  axis  of  the  appendix.  On  distention  they  become  flattened  out. 
If  the  appendix  be  cut  open  lengthwise  and  spread  out,  these  folds  are  ob- 
literated to  some  extent,  the  degree  depending  on  the  consistency  of  the  sub- 
mucosa. In  the  thin-walled  appendix  of  a  young  person  (Fig.  L15)  the  mucosa 
may  be  flattened  out  to  a  comparatively  smooth  surface;  while  the  hard  thick- 
walled  appendix  of  an  older  individual  will  not  permit  this.  The  mucosa  will 
then  be  seen  to  be  subdivided  into  many  dome-like  elevations  separated  by 
deep  furrows  (Fig.  116).  In  an  appendix  removed  at  operation  this  condition 
will  be  accentuated  through  contraction  of  the  muscular  coats,  which  would 
not  be  seen  in  an  autopsy  specimen.  The  mucosa  in  situ  appears  like  a  soft, 
thick  and  pulpy  membrane.  It  is  somewhat  yielding  and  is  the  most  fragile 
of  all  the  coats.  The  color  of  the  mucosa  is  a  light  brownish  flesh  tint,  some- 
times grayish,  and  its  surface,  while  glistening  to  some  extent,  has  a  velvety 
appearance,  due  to  innumerable  delicate  glandular  openings,  the  glands  of 
Lieberkuhn. 

These  openings  of  the  crypts  of  Lieberkuhn  are  arranged  with  remarkable 
regularity  around  certain  centres  marked  by  slight  depressions  on  the  surface, 
which  correspond  to  the  apices  of  the  lymph  follicles  (Fig.  116).  The  glandular 
openings  describe  lines  radiating  from  these  follicles  and  are  at  the  same  time 
arranged  concentrically  around  them.  Their  number,  as  well  as  the  distance 
between  them,  varies  according  to  the  age  of  the  individual.  There  are  about 
25-35  to  the  square  millimetre  in  the  adult — this  would  make  from  2500  to 
3500  to  the  square  centimetre.  Taking  the  average  circumference  of  the  lumen 
of  the  appendix  as  about  1  cm.,  its  length  as  8.3  cm.,  the  square  contents  of 
the  entire  mucous  surface  would  amount  to  8.3  sq.  cm.  This  multiplied  by 
the  average  number  of  glandular  openings  per  square  centimetre  (3000), 
would  result  in  a  total  number  of  about  25,000  glands  of  Lieberkuhn  contained 
in  an  average  appendix.  Their  opening  on  the  surface  is  not  funnel-shaped, 
but  abrupt  and  perfectly  round,  measuring  0.04  mm.  in  diameter.  Frequently 
the  circumference  of  the  lumen  is  as  great  as  that  of  the  serosa,  for  on  opening 
an  appendix  lengthwise  and  stretching  it  out  on  a  board,  the  mucous  surface 


MUCOSA. 


145 


:  >  .a 


Fig.  115. — A  Portion  op 
the  Mucous  Mem- 
brane op  a  Young 
Individual.  Show- 
ing the  Arrange- 
ment of  the  Lymph 
Nodes  on  the  Sur- 
face. 

Their  grouping  is 
fairly  regular  and  their  ex- 
posed surface  is  round  or 
oval,  sometimes  dumb-bell 
shaped.  Traversing  the 
surface  of  the  mucosa  are 
a  number  of  furrows  -hie 
to  the  folding  of  the  mem- 
brane when  in  situ.  (Nat- 
ural size.) 


is  seen  to  be  almost  as  large  as  the  peritoneal  surface.    These  calculations  were 

made  from  fresh  material,  as  alcohol  specimens  give  an  erroneous  impression, 

on   account  of  the  considerable   shrinkage  produced  by 

the  hardening  process.     The  glands  then  appear  much 

nearer  together,   a  square  centimetre  of  the  mucosa  of 

such  a  specimen  having  as  many  as  50  to  60  glandular 

openings.     In  a  distended  appendix  the  glands  are  always 

further  apart,  their  opening  is  wider,  and  they  are  seen  to 

dip  only  a  short  distance  into  the  mucosa.     The  glands 

are  less  abundant — that  is,  they  are  farther  apart  at  the 

tip  than  at  the  cecal  extremity  of  the  appendix. 

The  mucous  membrane  is  furnished  with  a  large  num- 
ber of  solitary  glands  or  follicles,  which,  however,  are  few 
and  far  between  compared  with  the  number  of  the  glands 
of  Licberkiilm  (Figs.  115  and  116).  The  exact  number  of 
follicles  contained  in  an  appendix  depends  upon  a  num- 
ber of  circumstances,  especially  upon  its  length  and  cali- 
bre. Lockwood  gives  150  to  200  as  a  rough  estimate  of 
the  number  of  follicles  contained  in  an  appendix  of  the 

usual  length,  S.5  cm.     I  find  the  number  varying  from  25  to  50  per  square  centi- 
metre, according  to  degree  of  distention,  age  of  the  individual,  and  location  of 

the    area  examined.     The    entire   appendix 
contains,  therefore,  between  300  and  400  fol- 
licles.    As  in  the  case  of  the  glands,  of  which 
only  the  opening  is  seen  from  the  surface, 
so  in  the  follicles,  merely  the  upper  portion 
sater  part  being  buried  be- 
lg  mucous  membrane.     The 
smooth,  and  as  it  does  not 
level  of  the  surface,  the  fol- 

[*r*BV'^r^K':;"i^<^vy;«'*S*^*-]       ''('lp  's  mai'ked  on  the  mucous  membrane  as 
'**** :  **  "•v •'•--•■'■•  SV*"       a  shallow  depression, 

Fio.  116. — The  Surface  of  the  Mucous 
Membrane  Magnified  6.5  Times. 
The  exposed  portion  of  the  follicles  is 
visible  as  a  dome-like  elevation  in  a  slight 
depression  in  the  mucosa.  Their  sijse  as 
well  as  their  outline  is  variable,  especially 
when  two  are  seen  to  fuse.  The  surface  of 
the  mucosa  between  these  nodes  is  studded 
with  minute  openings,  the  crypts  or  glands 
of  Lieberkiihn.  Their  arrangement  is  in 
rings  around  the  lymph  nodes  and  in  rows 
radiating  from  the  centre  of  the  follicle. 


depression,  the  bottom  of  which 

is  slightly  elevated  at  the  centre  (Fig.  114). 

The  exposed  portion  of  the  follicle  is  round 

or  oval,  sometimes   irregularly  shaped.     If 

two   are    fused   they  resemble  a  dumb-bell 

(Fig.   116).     The   average    measurement    of 

I  lie  exposed  portion  is  0.25  to  0.20  mm.  or 

less  in  diameter. 

On   microscopic   section    (transverse,    if 

not     otherwise     mentioned)     the    different 

structures   comprising   the   mucous   membrane   come   much    more   clearly   into 

view.     The  thickness  of  the  mucous  coat  in  the  fresh  specimen  varies  between 
10 


146  ANATOMY. 

0.3  and  0.7  mm.,  the  most  usual  measurement  being  0.45  mm.  The  lumen  of 
the  appendix  is  seen  to  have  an  irregularly  corrugated  or  wavy  outline,  the 
follicles  generally  lying  in  the  depressions  or  angles.  The  circumference,  with 
all  its  depressions  and  folds,  measures  almost  as  much  as  the  circumference 
of  the  peritoneal  coat.  In  beginning  obliteration,  however,  it  measures  much 
less.  For  these  reasons  the  measurements  vary  from  1  mm.  to  22  mm.,  or 
even  more. 

The  number  of  lymphatic  follicles  to  be  counted  in  one  section  varies  from 
3  to  8;  on  an  average  there  are  about  5.  Lockwood,  however,  found  12  in  a 
section  of  the  appendix  of  a  girl  aged  thirteen  years,  l(i  in  a  man  aged  thirty- 
five,  9  in  a  man  aged  thirty-seven,  8  in  a  man  aged  thirty-six,  and  5  in  a  man 
aged  sixty-eight.  In  any  one  section  all  the  follicles  are  rarely  cut  through  their 
centres,  most  of  them  being  sectioned  through  their  buried  portion;  hence  the 
occasional  appearance  that  the  follicles  do  not  reach  the  surface  (Fig.  112). 

The  mucous  membrane  consists  of  an  epithelium,  a  tunica  propria,  and  the 
muscularis  mucosa'.  The  epithelium  dips  down  into  a  great  number  of  simple 
tubular  glands,  the  crypts  of  Lieberkuhn,  between  which  lies  the  tunica  propria 
(Fig.  117).  In  an  ordinary  specimen  from  25  to  30  tubular  glands  can  be  counted 
in  one  section;  not  infrequently  there  are  40,  50,  or  even  00  well-developed 
glands.  They  rarely  show  dichotomous  branching.  Sometimes  they  are  found 
embedded  in  lymphoid  tissue  which  is  collected  at  certain  intervals  to  form  the 
follicles  or  lymph  nodes.  The  epithelium  which  covers  the  surface  of  the  mucosa 
and  is  continuous  with  the  lining  of  the  glands,  consists  of  a  layer  of  columnar 
cells  which  contain  a  granular  protoplasm,  numerous  fat  particles,  ami  usually 
an  oval  nucleus  and  a  cell  membrane.  Many  of  these  cells  show  the  common 
goblet  form.  There  is  also  a  homogeneous  basal  border  characteristic  of  the 
intestinal  epithelium.  The  regeneration  of  the  epithelium  taking  place  by  mitosis 
in  the  glands  of  Lieberkuhn,  causes  the  cells  to  gradually  move  upward  to  replace 
the  disintegrating  cells  on  the  surface,  though  mitosis  is  also  known  to  take 
place  in  the  latter.  The  youngest  generation  of  epithelial  cells  is,  therefore,  as 
a  rule  found  in  the  glands,  the  oldest  on  the  surface.  In  obliteration  of  the 
appendix  the  mucous  membrane  disappears  gradually,  being  shallowest  in  the 
corner  of  the  obliterating  angle.  It  is  probable  that  a  failure  of  the  epithelium 
of  the  glands  to  regenerate,  causes  the  mucous  membrane  to  disappear. 

The  tunica  propria  of  the  mucosa  fills  the  interspaces  between  the  glands 
and  consists  mainly  of  fibrillated  connective  tissue  and  reticulum  with  a  varying 
number  of  plasma  cells  and  small  round  cells.  The  reticulated  framework 
of  the  tunica  propria  is  in  intimate  connection  with  the  muscularis  mucosa'. 
The  mucosa  is  very  vascular,  containing  numerous  capillaries  and  a  few  lym- 
phatic channels. 

T  li  e  J.  y  m  p  h  X  o  d  e  s  (Fi<rs.  112  and  117). — The  lymph  nodes  de- 
velop in  the  tunica  propria  close  under  the  epithelium,  and  lie  with  their  base 
against   the  muscularis  mucosa'.     When  they  attain  their  full  size  they  expand 


LYMPH    NODES. 


147 


much  beyond  these  limits  and  invade  the  submucosa.     The  nodes  are  composed 
of  lymphoid  tissue  usually  containing  a  germinal  centre.     These  multiplying 


ne  \  on. . 

Fig.  117. — Portion  of  the  Normal  Mucous  Membrane  of  an  Appendix,  Magnified  150  Times. 

Above  is  the  lumen  of  the  appendix  into  which  are  seen  to  open  the  crypts  of  Lieberkiihn,  some  of  which 
are  cut  obliquely,  others  transversely.  The  epithelium  of  the  lumen  and  crypts  is  identical  and  consists  of  a 
single  layer  of  columnar  cells.  Between  the  crypts  or  glands  of  Lieberkiihn  is  the  tunica  propria,  consisting 
of  connective  tissue,  with  small  round  cells  and  a  few  plasma  cells.  The  lower  half  of  the  picture  is  chiefly  occu- 
pied by  a  lymph  node,  which  above  is  continuous  with  the  tunica  propria.  The  lymph  follicle  has  a  deeply  staining 
layer  of  lymphoid  cells  in  its  periphery,  while  the  germinal  centre  is  composed  of  more  faintly  staining  cells. 
Below  the  lymph  node  is  a  small  strip  of  submucosa  with  fat  globules  and  vessels,  and  beneath  this  are  a  few 
bundles  of  the  circular  muscular  coat. 


lymph  cells  of  the  central  portion  stain  more  faintly  than  the  lymphoid  cells 

forming  the  periphery.     The  arrangement  of  the  latter  is  concentric  (Fig.  117). 

The   thickness   of  the  mucosa   varies  greatly   in  different   individuals,   age 

being  the  main  factor  in  the  change.     The  usual  thickness  of  a  healthy  mucosa 


I  IS  ANATOMY. 

in  an  adult  is  from  0.2  to  ().'.',  mm.  measured  in  alcohol  specimens;  in  fresh  sjx>ci- 
mens  it  is  slightly  thicker.  The  height  of  the  follicles  varies  with  the  thickness 
of  the  mucosa.  In  young  individuals  they  arc  round  or  pear-shaped,  almost 
pyramidal,  with  their  point  projecting  into  the  lumen;  while  in  old  age  they 
flatten  out  with  the  mucosa.  They  are  also  much  nearer  together  in  youth, 
their  number  being  greater.  They  have  been  scon  to  form  an  almost  con- 
tinuous ring  of  lymphoid  tissue  on  cross  section  of  the  appendix  of  young  indi- 
viduals. In  the  adult  they  measure  aboul  1  mm.  or  slightly  less  at  their 
base,  and  are  distinctly  visible  to  the  naked  eye. 

The  crypts  of  Lieberkuhn  pass  at  right  angles  to  the  surface  with  the 
exception  of  those  lying  near  the  follicles,  which  are  directed  obliquely  toward 
the  surface,  hugging  the  sides  of  the  follicle,  at  the  same  time  decreasing  in 
length,  those  nearest  the  follicles  being  the  shortest  (Fig.  112). 


CONTENTS  OF  THE  APPENDIX. 

The  ordinary  and  normal  appendix  may  contain  focal  matter  similar  to 
thai  found  in  the  adjacent  large  intestine,  and  varying  in  quantity  according 
to  the  size  of  the  lumen.  By  drawing  the  fingers  over  the  surface  of  the  appen- 
dix and  pressing  gently  at  the  same  time,  its  contents  may  he  moved  from 
point   to  point,  or  may  even  ho  pushed  entirely  hack  into  the  cecum. 

On  opening  up  the  appendix  it-  contents  are  seen   to  he  of  a  yellowish  or 

greenish  tinge,  and  of  a  -oft  consistency.  Not  infrequently  the  lumen  i<  filled 
with  a  mucous  or  serous  liquid  which  is  of  a  transparent  or  slightly  muddy 
character. 

Sometime-  the  appendix  appears  to  he  quite  empty,  a  condition  associated 
usually  with  a  narrow  diameter  and  an  efficient  valve.  As  a  rule  the  greater 
the  diameter  of  the  appendix,  the  greater  is  the  probability  of  finding  fecal 
matter  within  its  lumen.  A  straight  or  slightly  curved  appendix  also  i^  more 
apt  to  contain  fecal  matter  than  a  convoluted  or  kinked  appendix. 

The  cavity  of  the  fetal  appendix  almost  invariably  contains  fecal  matter, 
which  CLADO  says  can  he  seen  with  the  naked  eye  after  the  sixth  month  of 
intrauterine  life.  Under  the  microscope  it  has  the  appearance  of  a  mass  of 
granule-  and  -mall  cellular  particles  united  by  mucus.  After  birth  the  contents 
of  the  appendix  are  similar  to  those  of  the  adult.  Among  101)  infant  and  fetal 
appendices,  Vali.kk  found  70  containing  fecal  matter  (usually  soft),  24  con- 
taining mucous  or  serous  liquid,  while  (i  were  empty.  Bryant  found  fee,]] 
matter  in  70  per  cent,  of  his  adult  specimens,  the  others  being  either  empty  or 
containing  foreign  bodies  of  the  usual  description.  These  he  find-  to  be  more 
frequent  in  male  than  in  female  subjects. 

The  fecal  matter  within  the  appendix  sometimes  becomes  hard  and  even 
calcareous,  forming  the  so-called  "fecal  concretions."  If  present  these  are 
often  seen  and  felt  from  the  outside,  their  presence  causing  a  swelling  of  the 


OBLITERATION    DUE    TO    INVOLUTION.  149 

appendix.  They  can  readily  he  moved  about  within  the  lumen,  provided  they 
are  not  too  large.  If  several  of  them  come  in  contact  with  one  another  they 
are  apt  to  appear  faceted,  in  which  case  they  may  resemble  gall-stones.  Many 
cases  are  on  record  of  foreign  bodies  which  have  entered  the  lumen  of  the  ap- 
pendix through  the  ceco-appendical  valve;  but  these,  together  with  the  resulting 
pathological  conditions,  will  be  dealt  with  in  another  chapter.    (See  Chapter  XVI.) 


OBLITERATION  OF  THE  APPENDIX. 

While  some  authors,  as  Bierhoff  and  Fitz,  trace  obliteration  back  to 
previous  inflammatory  conditions,  others,  as  for  instance.  Ribbekt,  consider  it 
as  a  process  of  involution,  which  is  a  demonstration  of  the  general  retrogressive 
character  of  the  organ.  Each  conception  is,  no  doubt,  correct  if  restricted  to 
its  separate  process,  that  is  to  say,  to  pathological  obliteration,  or  to  involution. 
This  section  deals  entirely  with  the  latter,  namely,  obliteration  due  to  involu- 
tion advancing  from  the  tip. 

Obliteration  is  much  more  frequent  than  is  generally  supposed.  In  exam- 
ining the  appendix  of  a  middle-aged  person  a  probe  will  sometimes  not  pass 
through  the  lumen  of  the  appendix.  But  occasionally,  this  obstacle  may  he 
overcome  by  more  pressure,  when  the  probe  will  penetrate  through  a  narrow 
channel.  If  obliteration  is  complete,  the  opening  of  the  appendix  into  the 
cecum  is  either  not  noticeable,  or,  if  present,  is  indicated  by  a  funnel-shaped 
depression.  From  without  it  is  not  always  to  be  determined  whether  the 
lumen  is  obliterated  or  not.  Generally  the  obliterated  part  is  thinner  than 
the  partly  obliterated  portion,  and  much  thinner  than  normal.  There  is, 
however,  no  absolute  criterion.  Only  a  great  degree  of  lessening  of  calibre 
is  a  reliable  test.  On  the  other  hand  the  obliterated  portion  may  be  thicker 
than  the  normal. 

One  true  external  test  of  obliteration  is  a  club-shaped  end  of  the  appendix. 
This  does  not  consist  so  much  in  thickening  of  the  tip,  as  in  thinning  out  of 
a  neck-shaped  portion  just  before  it.  an  elongated  oval  portion  differentiated 
from  the  rest  of  the  organ  being  thus  formed  at  the  end.  The  club  is  gener- 
ally as  thick  as  the  rest  of  the  appendix,  and  may  be  thicker. 

E  x  t  ens  i  o  n  of  the  0  b  1  i  t  e  rati  o  n  . — A  transverse  section  of  an 
obliterated  appendix  shows  three  distinct  layers: 

1.  A  central  layer  more  or  less  rich  in  cells,  corresponding  to  the  mucosa, 
and  gradually  passing  into: 

'2.  A  layer  of  connective  tissue,  poorer  in  cells,  and  corresponding  to  the 
submucosa. 

3.  A  layer  of  muscle,  and  the  usual  serous  envelopment. 

The  centre  sometimes  shows  an  indication  of  the  original  lumen.  More 
careful  observation  shows  that  there  may  be  no  lumen  at  all,  but  merely  a  deli- 
cate zone   of   central  tissue  consisting  of  fibres    and  nuclei.        It   is   possible  to 


I  ."ill  WATOMY. 

tear  this  fragile  substance,  hence  the  possibility  of  piercing  it   by  the  use  of 
greater  pressure  in  testing  the  lumen  with  a  probe. 

The  inner  layer  is  often  irregularly  radiating,  having  a  concentric  arrange- 
ment of  cells  which  follow  the  course  of  the  original  blood-vessels  and  glands. 
The  differentiation  between  this  layer  and  the  second,  the  submucosa,  is  gradual. 
The  muscle  as  a  rule  shows  no  change. 

The  manner  in  which  obliteration  takes  place  is  best  studied  at  the  margin 
between  normal  and  obliterated  parts;  the  process  is  briefly  as  follows: 

The  glands  become  lost,  and  simultaneously  there  takes  place  a  fusion  of 
connective  tissue  between  the  glands.  In  some  cases  there  is  nothing  abnormal 
to  lie  noticed  until  the  obliterated  part  itself  is  reached,  the  glands  being  pre- 
served up  to  the  very  apex  of  the  obliteration. 

In  other  cases  the  glands  in  the  neighborhood  of  the  occlusion  become  more 
scarce  and  are  seen  to  be  less  well  developed;  or  they  may  be  lacking  altogether 
for  some  distance.  On  the  advancing  margin  of  the  process  of  obliteration, 
and  especially  in  the  funnel  or  apex  of  the  occlusion,  there  are  none  at  all. 
In  some  cases  there  is  a  region  1  or  5  mm.  before,  or  proximal  to  the  seat  of  the 
obliteration,  which  is  entirely  lacking  in  glands.  In  one  of  Ribbert's  cases, 
h  cm.  before  the  obliterated  portion  there  was  found  an  area  containing  no 
glands,  but  still  lined  by  a  regular,  single,  well-developed  layer  of  cylindrical 
epithelium  with  numerous  Becker  Zellen.  Toward  the  cecum  this  became 
continuous  with  normal  mucous  membrane.  As  the  surface  epithelium  was 
often  lacking  in  the  specimens,  it  was  difficult  to  determine  accurately  the 
condition  of  the  mucosa. 

Obliteration  is  associated  with  a  destruction  of  the  glands.  The  fusing 
of  the  connective  tissue  advancing  toward  the  cecum,  forces  the  epithelium 
along  with  it.  The  follicles  ami  glands  at  the  tapering  end  of  the  funnel  do 
not  show  any  marked  changes.  The  former  are  generally  small,  corresponding 
to  those  in  normal  appendices.  They  do  not  take  part  in  the  process  of  oblitera- 
ton  as  they  simply  disappear  in  the  fusing  connective  tissue.  In  some  isolated 
cases  there  are  remains  of  them  in  the  obliterated  portion,  appearing  as  small 
accumulations  of  densely  packed  cells,  showing,  rarely,  a  lighter  centre.  They 
are  seen  only  in  the  angle  or  apex  of  the  funnel,  not  in  the  obliterated  portion 
itself.  They  lie  centrally  and  are  very  few  in  number,  only  one  or  two 
appearing  generally  in  a  section. 

Frequency. — Among  the  400  cases  examined  by  Ribbert,  99  showed  partial 
or  total  occlusion,  ?'.  <■.,  25  per  cent.  In  the  appendices  of  persons  over  twenty 
years  of  age  the  percentage  is  about  one-third,  or  .32  per  cent. 

While  the  obliteration  in  a  very  small  number  of  cases, :p  per  cent.,  involved 
the  entire  appendix,  partial  occlusion  is  much  more  frequent.  All  transition 
forms,  from  the  first  beginning  of  occlusion  to  its  completion,  are  met  with. 

In  one-half  the  cases,  the  obliteration  involves  one-fourth  of  the  appendix; 
in  one-half  of  the  remaining  cases  it  involved  one-fourth  to  three-fourths  of 


OBLITERATION'    OF    APPENDIX.  151 

the  organ;  and,  as  was  said  above,  only  a  very  small  percentage  showed  three- 
fourths  or  the  whole  appendix  occluded.  The  sexes  furnish  about  an  equal 
number  of  cases. 

Increase  in  age  is  shown  to  bring  increase  in  obliteration: 

1  to  10  years,  obliteration  found  in  4  per  cent. 

10  to  20  "  "  "  11 

20  to  30  "  "  "17 

30  to  40  "  "  "  25 

40  to  50  "  "  "  27 

50  to  GO  "  "  "  36 

60  to  70  "  "  "  53 

70  to  80  "  "  "  58 

This  table  shows,  therefore,  that  of  all  people  over  sixty  years,  more  than 
one-half  show  obliteration. 

In  the  new-born,  obliteration  was  never  found.  The  youngest  child  that 
showed  it  was  five  years,  and  this  was  not  a  typical  case.  In  Ribbert's  series, 
a  total  obliteration  never  occurred  before  the  thirtieth  year.  It  is  very  prob- 
able that  quite  a  number  of  these  obliterated  appendices  were  produced 
by  pathological  changes,  for  as  age  advances,  the  relative  frequency  of 
appendicitis  increases  in  about  the  same  ratio  as  that  given  in  this  table. 

Relation  b  e  t  w  e  e  n  L  e  n  g  t  h  and  Obliteratio  n  . — Of  the 
longest  appendices.  15  to  20  cm.,  all  were  found  patent;  of  those  14  to  13  cm. 
long,  one  out  of  four  had  beginning  obliteration;  in  a  length  of  12  to  11  cm., 
not  one  was  obliterated. 

The  rest  of  the  table  shows  that  decrease  of  length  generally  brings  an 
inclination  to  obliteration: 

In  those  of  10  cm 34  per  cent,   was  obliterated. 

9  cm 18 

5  cm 32 

7  cm 40 

6  cm 30 

5  cm 70 

4  cm 66 

3  cm 100 

While  no  absolute  regularity  can  lie  made  out,  short  appendices  are,  as  a 
rule,  found  to  lie  more  frequently  obliterated  than  long  ones. 

Causes  of  Obliteration  . — The  question  whether  old  healed  in- 
flammatory conditions  are  the  cause  of  obliteration  can  be  determined  in  most 
cases  by  examining  the  entire  serosa  and  mucous  membrane,  although  there  is 


152  INATOMY. 

no  doubt  that  even  then  it  may  sometimes  be  difficull  to  decide  whether  the 
process  is  ool  due  to  the  other  factor. 

Serosa.  Adhesions  of  the  appendix  with  surrounding  organs  arc  frequent 
and  arc  a  sign  of  old  inflammatory  conditions.  Frequently  a  kink  is  found  in 
an  obliterated  appendix,  but  since  it  has  been  found  thai  every  fourth  appendix 
is  obliterated  with  or  without  a  kink,  this  proves  nothing.  Mosl  appendices 
about  to  become  occluded  by  involution  arc  tree  of  any  adhesions  ami  kink-. 

Muco  a.  Signs  of  inflammation  in  the  mucous  membrane  itself  must, 
therefore,  he  sought  for.  but  R.IBBERT  found  none,  which  however  docs  not 
necessarily  prove  that  in  a  certain  percentage  of  his  cases  they  were  no1 
present  at  an  earlier  stage  of  the  process. 

The  atrophy  of  the  mucous  membrane  has  apparently  nothing  to  do  with 
obliteration,  because  it  occurs  in  appendices  of  old  individuals  with  a  wide 
lumen. 

While  Ribbeet  and  Zuckerkandl  go  too  far  in  their  assertion  that 
obliteration  is  always  caused  by  involution,  there  is  undoubtedly  a  certain 
class  of  cases  in  which  the  pathological  clement  may  safely  he  excluded. 

The  presence  of  a  layer  of  connective  tissue  strands,  originating  in  the 
mucosa;  the  unchanged  structure  of  the  submucosa  and  muscularis;  the  lack 
of  all  irregularity  and  especially  the  lack  of  any  scar-like  change  which  might 
signify  an  old  healed  inflammatory  process;  all  these  an'  points  which  signify 
that  involution  is  often  the  cause  of  obliteration.  And.  lastly,  what  disease 
would  attack  the  end  of  the  appendix  with  such  regularity,  beginning  always  at 
the  tip  ami  advancing  toward  the  cecum,  gradually  closing  up  the  lumen'.' 

While  pathological  obliteration  may  occur  at  the  tip.  it  is  by  no  means 
confined  to  it,  hut  is  found  frequently  in  other  portions  of  the  appendix. 
Microscopic  sections  will  generally  furnish  means  to  distinguish  such  pathological 
obliteration  from  the  distal  obliteration  due  to  involution. 


RETROGRESSION. 
The  early  differentiation  of  the  appendix  verniifonnis  from  the  cecum,  of 
which  it  is  hut  the  continuation,  its  relatively  greater  length  in  the  fetus  ami 
new-horn  as  compared  with  the  adult,  together  with  many  signs  of  atrophy 
in  the  organ  during  later  life,  seem  to  indicate  that  the  appendix  is  a  disap- 
pearing or  retrogressive  organ.  In  shape  and  outline  the  cecum  shows  con- 
siderable variation  during  the  course  of  its  development.  Starting  between 
the  fifth  and  sixth  weeks  as  a  slight  elevation  or  bulging  from  the  left  side  of 
the  caudal  loop  of  the  intestine,  at  seven  weeks  or  more  it  i-  a  rounded  or  conical 
projection,  with  a  contracted  portion  at  it-  apex  or  tip  which  appeal-  like  a 
budding  appendix.  This  type  of  cecum,  the  seven  week-  stage,  is 
permanently  represented  in  anatomy  by  that  of  the  Mangabey  monkey.  (See 
Fig.  63.)      At    eight    weeks,    where    the  cecum   is   four  or  five  times  as 


RETROGRESSION   OF   APPENDIX.  153 

long  as  it  is  broad,  but  still  scarcely  differentiated  from  the  cecum  or  end  portion 
of  the  large-  intestine,  we  have  the  type  of  cecum  represented  by  Ateles  the 
Spider  monkey  (Fig.  til),  and  many  other  animals. 

Later  on,  the  tube  increases  greatly  in  length,  but  not  correspondingly  in 
thickness  except  in  its  upper  portion.  We  now  have  a  long,  slender  diver- 
ticulum, the  appendix  vermiformis,  attached  at  its  widened  base  to  a  rounded 
projection  from  the  bowel,  the  cecum  proper.  At  this  stage  the  cecum  may 
pass  gradually  into  the  appendix,  forming  the  conical  or  typical  fetal  type  of 
cecum.  Something  similar  to  this  type  is  seen  in  the  tapering  cecum  of  the 
kangaroo  (Fig.  65),  and  it  is  sometimes  found  persisting  in  the  adult  human 
body. 

On  examining  the  cecum  of  many  of  the  higher  animals,  its  shape  and  size 
are  found  to  bear  an  important  relation  to  the  mode  of  alimentation.  The 
herbivorous  animals  possess  an  enormous  cecum,  bending  and  curving  like  the 
human  appendix,  while  in  carnivora  it  is  very  small  and  simple,  or  may  be 
entirely  wanting.  In  man,  apes,  and  many  rodents,  which  have  a  mode  of 
alimentation  midway  between  these  two,  a  portion  of  the  cecum  undergoes  a 
retrogressive  change,  so  that  a  thin,  worm-like  process  is  left  attached  to  the 
cecal  pouch.  The  retrogression  is  probably  due  to  a  change  in  the  character 
of  the  nourishment  which  has  taken  place  during  the  history  of  the  species. 
According  to  Grohe,  the  disappearance  of  the  last  molar  tooth,  which  comes 
late  in  life,  is  another  indication  of  the  change  from  an  herbivorous  to  an  om- 
nivorous character  in  the  diet  of  man.  The  relatively  large  size  of  the  human 
cecum  and  appendix  in  the  fetus  and  new-born  indicate  that  this  time  does 
not  lie  very  far  back  in  the  history  of  man. 

It  is  the  rudimentary  character  of  the  appendix  which  is  responsible  for 
much  of  the  variation  in  position,  shape,  and  size  which  we  find  in  this  structure. 

According  to  Huntington  the  appendix  is  probably  destined  for  further 
reduction  and  ultimate  elimination.  The  appendix  presents  the  indefinite 
character  in  regard  to  anatomical  arrangement  which  belongs  to  such  struc- 
tures. The  uncertain  type  of  development  due  to  this  element  expresses  itself 
in  the  varieties  of  forms  presented  by  the  adult  cecum. 

'While  there  is  no  doubt  that  the  appendix  has  all  the  signs  of  an  organ 
passing  through  the  different  steps  of  retrogression,  the  process  being  at  the 
present  time  still  in  the  initial  stages,  it  cannot  be  denied  that,  as  long  as  the 
organ  is  nol  obliterated,  it  is  capable  of  performing  its  share  of  the  work  as  a 
portion  of  the  alimentary  canal,  though  only  on  a  comparatively  small  scale. 

All  structures  of  the  human  body  which  are  not  in  constant  use.  soon  become 
atrophied,  a  few  weeks  of  nnn-use  sufficing  to  cause  the  muscles  to  disappear. 
The  same  is  the  case  with  epithelial  elements,  which  vanish  if  not  called  upon 
to  functionate.  The  muscle,  epithelial  and  endothelial  cells  are  replaced  by 
connective  tissue  cells,  which  in  turn  become  absorbed  to  a  certain  extent. 
Such  a  process  is  observed,  as  we  have  learned,  in  about  one-fourth  of  all  ap- 


I.".  1  ANATOMY. 

pendices,  and  in  a  much  larger  percentage  in  old  age.  There  remains,  however, 
the  overwhelming  majority  of  appendices  in  children,  in  the  middle  aged,  and 
even  in  very  old  individuals,  which  show  no  change  indicating  that  the  epithelial 
and  muscular  structures  have  ceased  to  functionate.  The  blood  and  lymph 
supply  and  the  uerves  are  also  very  well  developed  and  remain  so  during  the 
greater  part  of  life,  or  even  throughout  the  whole  of  it.  Even  if  the  mucosa 
gradually  undergoes  atrophy  as  age  approaches,  the  same  is  known  to 
be  the  case  with  the  cecal  and  colic  mucosa  (according  to  Nothnagel,  in  80 
per  cent,  of  the  cases)  or  any  other  epithelial  structures  of  the  human  body,  in 
connection  with  which  no  one  would  apply  the  term  "rudiment." 

These  facts  indicate  that  the  appendix  retains  for  a  considerable  time 
the  same  energy  as  the  cecum,  and  that  its  muscular  coats  are  capable  of 
producing  an  active  peristalsis,  perhaps  of  greater  .strength  in  relation  to  it-  size 
than  is  the  case  in  any  other  part  of  the  intestine. 


CHAPTER  VII. 
ANATOMY. 

THE   ARTERIES   OF  THE   APPENDIX.     THE  VEINS  OF   THE  APPENDIX.     THE 
LYMPHATICS  OF  THE  APPENDIX.     THE  NERVES  OF  THE  APPENDIX. 

THE  ARTERIES  OF  THE  APPENDIX. 

The  vascular  supply  of  the  ileocecal  region  comes  from  the  ileocolic  artery, 
the  lower  division  of  the  right  colic  branch,  which  in  turn  is  derived  from  the 
superior  mesenteric  artery.  There  are  but  slight  variations  of  the  topogra- 
phy of  the  ileocolic  artery,  the  most  noteworthy  of  which  is  a  separate  origin 
from  the  superior  mesenteric  below  that  of  the  right  colic  branch. 

The  ileocolic  artery  passes  obliquely  downward  in  the  mesentery  toward 
the  ileocolic  angle,  where  it  divides  into  the  anterior  and  posterior  ileocecal 
arteries,  the  appendical  artery  or  arteries,  an  ascending  colic  branch,  anasto- 
mosing with  the  right  colic,  and  one  or  more  branches  to  the  ileum  which 
anastomose  with  the  adjacent  loops  of  the  vasa  intestini  tenuis,  the  terminal 
branches  of  the  superior  mesenteric.  Short  anastomoses  are  frequently  found 
between  these  branches  near  their  origin  from  the  ileocolic  artery,  and  as  a 
result  a  somewhat  complicated  network  arises,  in  consequence  of  which  it  is 
often  difficult  to  determine  the  exact  origin  of  the  appendical  and  other  arteries 
without  careful  dissection  (Fig.  US  ami  Figs.  1_'2-138). 

The  anterior  ileocecal  artery  travels  forward  and  obliquely  downward  over 
the  cecum  in  the  ileocolic  fold  (Fig.  IIS).  The  position  of  the  fold  is  largely 
determined  by  the  presence  of  the  artery,  which,  together  with  its  vein,  is  thus 
somewhat  protected  against  extreme  tension  produced  by  abnormal  distention 
of  this  portion  of  the  intestine.  The  majority  of  the  branches  of  the  anterior 
ileocecal  artery,  from  4  to  S  in  number,  pass  to  the  right  over  the  cecum,  being, 
as  a  rule,  situated  at  the  depth  of  the  transverse  depressions.  They  give  off 
branches  which  pass  out  over  the  pouches  of  the  cecum;  while  the  main  trunks 
continue  outward  and  pass  beneath  the  anterior  muscular  band.  Here  they 
break  up  into  finer  branches  which  anastomose  with  those  of  the  posterior 
ileocecal  artery.  The  anterior  ileocecal  artery  also  gives  off  one  or  more  small 
branches  to  the  terminal  portion  of  the  ileum.  Usually  there  is  but  one  such 
branch,  which  travels  out  on  the  surface  of  the  ileum  parallel  with  its  axis 
and  supplies  its  lower  anterior  wall,  the  upper  portion  being  supplied  by  mesen- 
teric branches.     From  this  artery  small  branches  frequently  descend  into  the 

155 


I  ."ill  ANATOMY. 

ileocecal  fold,  which  connects  with  the  mesappendix,  where  they  anastomose 
with  branches  arising  from  the  appendix  (Fiji.  1  IS i. 

The  posterior  ileocecal  artery  is  qoI  situated  in  a  fold  like  the  anterior  ileo- 
cecal, and  pursues  a  straighter  and  shorter  course  than  the  latter.  It  supplies 
the  posterior  wall  of  the  cecum,  its  branches  traveling  in  the  depressions  be- 
tween the  saccular  like  those  on  the  anterior  surface,  then  penetrating  beneath 
the  posterior  muscular  hand  and  terminating  in  the  lateral  wall,  anastomosing 
with  branches  of  the  anterior  system.  Hesides  the  cecal  branches,  the  posterior 
ileocecal  artery  may  give  off  a  branch  passing  through  the  mesentery  to  the 
ileum  and  one  or  more  to  the  appendix.  The  lower  branches  of  the  posterior 
ileocecal  artery  frequently  supply  nol  only  the  median  and  posterior  walls 
of  the  cecum,  but  crossing  the  line  of  attachment  of  the  mesappendix  they 
encroach  upon  the  anterior  surface  of  the  cecum,  anastomosing  with  the  branches 
of  the  anterior  ileocecal  artery  above  and  the  artery  of  the  appendix  beneath. 

The  origin  and  number  of  arteries  to  the  appendix  vary  considerably.  (See 
Types  I,  II,  III,  and  IV.  Figs.  122  L27,  128-131,  132-136,  and  137-138.)  In 
I  lie  majority  of  cases  there  is  one  main  appendical  artery  which  arises  either  from 
the  ileocolic  artery  direct,  or  from  the  posterior  ileocecal  or  one  of  its  branches, 
or  from  a  branch  in  the  mesentery  of  the  ileum  near  its  origin.  This  appendical 
artery  passes  down  behind  the  terminal  portion  of  the  ileum,  and  is  enclosed 
between  the  two  peritoneal  leaves  of  the  mesappendix.  The  formation  of  the 
latter  is  determined  by  the  artery.  It  is  usually  found  along  the  free  edge  "I' 
the  mesappendix;  in  its  upper  portion,  however,  it  may  he  some  distance  from 
it,  or  in  cases  where  a  large  amount  of  fat  is  present  in  the  mesappendix, 
its  position  may  be  still  farther  from  the  edge.  In  all  but  one  of  the  cases 
examined  it  traveled  to  the  very  tip  of  the  appendix,  usually  curving  around 
the  latter  and   penetrating  it  directly,  as  do  the  branches  along  the  hiluni  or 

mesappendical  border.  'See  Figs,  ill  and  lbs.)  In  over  one-third  of  the 
cases  studied  this  main  appendical  artery  supplied  the  entire  appendix,  Type 

1.  and  sometimes  a  little  of  the  adjoining  portion  of  the  cecum  (Type  III, 
Fig.  132).  In  the  remainder  of  the  cases  it  supplied  the  distal  four-fifths  of 
the  organ,  while  a  second,  or  even  a  third  appendical  artery  supplied  the 
remaining  proximal  portion,  (Type  II,  Figs.  128  131),  and  anastomosed  with 
the  cecal  branches  (Type  III,  Figs.  133  L36  and  Type  IV.  Figs.  137-138.) 

The  main  appendical  artery  gives  off.  on  an  average,  five  secondary  branches, 
which  take  a  direct  mute  to  the  appendix  (Fig.  llsi.  Frequently  there  are 
only  three  branches  (Clado),  yet  in  cases  where  the  appendical  arteries  form 
loops,  as  many  as  ten  or  twelve  branches  are  sometimes  found.  These  branches 
pursue  an  oblique  course  in  the  mesappendix  toward  the  hiluni  of  the  organ, 
and  decrease  in  length  as  the  mesappendix  narrows  down  at  the  tip.  In  cases 
where  the  mesappendix  appears  to  end  some  little  distance  from  the  tip,  the 
artery  may  still  lie  found  just  beneath  the  peritoneum,  where  it  travels  until 
it  reaches  the  tip  (Fig.  119).     Some  authors  state  that  the  mesappendix  fre- 


1 


In,,  lis. — The  Blood-vessels  of  the  Ileocecal  Region. 
Arteries  red,  veins  blue.  The  peritoneal  covering  i>  removed  so  as  to  3how  the  vessels  more  clearly.  Above 
and  to  the  right  are  seen  the  cut  ends  of  the  ileocolic  artery  and  vein.  This  artery  gives  off  a  branch  to 
the  ascending  colon  and  :i  po.-terior  and  anterior  cecal  artery,  t he  latter  descending  through  the  ileocolic  fold, 
A  short  anas t "ii in- 1-  connects  the  ileocolic  with  the  mesenteric.  The  artery  of  the  appendix  is  seen  to  arise  from 
the  posterior  cecal  artery,  2  cm.  above  t he  ileum.  It  passes  behind  the  ileum  in  the  free  border  of  the  tnesap- 
pendix  and  gives  off  rive  branches  (long  appendices  have  8-  12,  short  appendices,  2-3),  which  traverse  the  mes- 
appendix  at  fairly  regular  intervals  in  the  direction  of  the  hilum  of  the  appendix,  where  they  divide  into  anterior 
and  posterior  branches.  The  branches  in  the  mesappendix  are  sometimes  seen  to  anastomose,  forming  loops 
of  varying  size.  The  terminal  branch  curves  around  the  tip.  The  ceco-appendical  junction  is  supplied  by 
a  separate  branch  arising  likewise  from  the  posterior  ileocecal  trunk.  This  branch  may  or  may  nol  anastomose 
with  the  proximal  appendical  twig  and  while  in  some  cases  it  supplies  onl:  the  cecum,  in  others,  as  in  the  present 
case,  it  -ends  a  few  delicate  branches  into  the  appendix.  At  the  place  where  this  ceco-appendical  artery  cr> 
the  ileocecal  fold  it  is  seen  to  give  off  a  delicate  recurrent  twig  to  this  structure.  Throughout  their  entire  course 
the  arteries  are  accompanied  by  veins. 


157 


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Flo.    121.  -A    Portion  op  the  Mucosa,  Injected  and  Cleared  in  Creosote,  to  show  the  Blood-vessels 

M  LGNIFIED    Ml    TlMEB. 

Below  are  the  vessels  of  tlie  submucosa.  The  artery  ascends,  dividing  until  the  base  of  the  glands  is  reached, 
where  ;i  small  plexus  is  formed,  from  which  delicate  i»i|_'<  invade  the  tunica  propria  between  the  glands.  Around 
the  mouths  of  the  glands  there  is  a  tortuous  capillary  network.  (See  also  mucous  surface  oi  reconstruction. 
Fig.  120.)  The  descending  collecting  veins  form  a  miniature  forest  between  the  glands  whose  root-  i  the  venous 
plexus  at  the  base  of  the  glands      This  plexus  drains  into  the  .submucous  plexus. 


ARTKKIKS    OF    APPENDIX.  I  til 

quently  extends  only  two-thirds  or  even  one-half  the  length  of  the  appendix, 
and  that  the  artery,  penetrating  the  hilum  some  distance  from  the  tip,  may 
leave  the  terminal  portion  insufficiently  supplied  with  blood  and  therefore  subject 
to  disease.     Our  observations,  however,  demonstrate  that  this  is  not  the  ease. 

Having  reached  the  hilum  of  the  appendix  each  branch  of  the  appendical 
artery  subdivides  into  two  or  more  sub-branches  before  penetrating  the  coats. 
The  division  usually  takes  place  close  to  the  mesenteric  border  or  hilum,  hut 
it  may  occur  farther  up  in  the  mesappendix  ( Figs.  1  Is  and  120).  These  branches 
separate  on  either  side  of  the  appendix  and  form  two  main  systems  within 
the  coats, — the  superficial  in  the  serous  coat,  and  the  deep  in  the  submucosa. 
They  contain  the  largest  vessels  and  are  the  bases  of  blood-supply  for  the  other 
coals  (Fig.  L20).  Those  which  lie  just  beneath  the  peritoneum  may  be  seen 
from  the  surface  pursuing,  sometimes,  a  very  tortuous  path  and  standing  out 
prominently  in  cases  of  inflammation  of  the  appendix.  They  pass  around  the 
siiles  of  the  appendix,  dividing  into  numerous  ramifications  and  frequently 
anastomosing  along  its  free  border.  Most  of  the  superficial  large  vessels  remain 
immediately  beneath  the  serous  coat,  and  from  them  finer  branches  are  sent 
inward  which  supply  the  muscular  coats.  They  follow,  in  general,  the  direction 
of  the  fibres,  passing  longitudinally  down  the  appendix  in  the  outer  coat  ami 
around  it  in  the  inner  or  circular  coat.  The  arteries  in  these  coats  are  delicate, 
the  supply  being  not  conspicuously  great  between  the  two  coats. 

The  large  vessels  which  penetrate  the  muscular  coats  at  the  hilum.  after 
giving  off  small  branches  to  the  adjacent  tissue,  pass  directly  into  the  sub- 
mucosa, where  they  form  a  close  network  about  half  way  between  the  muscular 
and  mucous  coats  (Fig.  120).  From  this  network  a  few  brandies  are  sent 
outward  into  the  muscular  coats,  but  the  majority  of  its  branches  go  toward 
the  mucous  coat.  Leaving  the  large  vessels  in  the  submucosa  they  ramify 
around  the  follicles  and  at  the  base  of  the  glands,  supplying  each  with  numerous 
fine  branches.  Viewed  from  the  mucous  surface  of  an  injected  specimen, 
cleared  in  creosote,  large  vessels  may  be  seen  ascending  vertically  between 
the  follicles,  and  numerous  branches  are  seen  entering  the  lymph-follicles  from 
all  siiles  and  converging  toward  the  centre  of  each.  At  the  base  of  the  glands 
of  Lieberkuhn  the  arteries  usually  spread  out  for  some  distance  parallel  with 
the  fibres  of  the  muscularis  mucosa,  and  from  this  system  the  liner  branches 
ascend  between  thi'  glands  i  big.  121 ).  They  pursue  either  a  straight  or  oblique 
course,  branching  in  a  fork-like  manner  ami  terminating  in  a  capillary  network 
around  the  mouths  of  the  glands.  Concerning  the  further  course  of  the  ap- 
pendical blood  see  "  Veins,"  \>.  166. 

The  mesappendix  is  everywhere  supplied  with  a  network  of  anastomosing 
vessels,  and  near  the  appendix  thin-  frequently  form  arches  between  the  larger 
trunks.  The  masses  of  fat.  wherever  present,  are  richly  supplied  with  a  network 
of  very  delicate  vessels. 

Through  a  canula  inserted  into  one  of  the  four  or  five  branches  of  the 
it 


L62 


\N  \TOMY. 


appendical  artery,  more  than  one-half  of  the  appendix  may  be  injected  at  once, 
which  demonstrates  connection  between  the  areas  supplied  by  the  different 
branches.  If  one  near  the  cecum  be  chosen,  a  circular  area  of  the  cecum  around 
the  appendical  orifice,  measuring  from  1  to  2  cm.  in  diameter,  may  be  injected 
as  well  as  the  appendix.  This  may  he  done  in  three  ways. — I.  through  a  small 
cecal  twig  or  twigs  coming  off  from  the  appendical   branch   near   the   ceco- 


fe} 


Fig.  122. — Type  [,a.    One  Artery,  Supplying  oni.y 
the  Appendix.     Origin:   Ileocolic. 


Fig.  123. — Type  1.  b.    One  Artery,  Supplying  only 
the  Appendix      okk.i\     CusiKitnm  Ileocecal. 


Fig.  124.— Type  I.  c.    One  Artery,  Supplying  only 
the  Appendix.     Origin:  Anterior  Ileocecal. 


Fig.  125. — Type  I.  d.  One  Artery,  Supplying  only 
the  Appendix.  Origin:  Mesenteric  Branch 
op  Ileocolic. 


appendical  angle  (Figs.  132  136);  II.  through  a  broad  arterial  communication 

inside  the  wall  of  the  ceco-appendieal  junction  such  as  shown  in  Fig.  119; 
III,  if  neither  the  cecal  twig  nor  an  arterial  anastomosis  is  present,  the  in- 
jection mass  passes  through  the  capillaries  of  the  appendico-cecal  junction 
and  invades  the  adjacent  cecal  territory  through  the  venous  system,  whose 
branches  anastomose  more  freely  than  those  of  the  arteries. 

The  appendical  artery  or  one  of  its  proximal  branches  usually  gives  off  a 


BRANCHES    DERIVED    FROM    ARTERIES    IX    MESAPPENDIX. 


L63 


recurrent  branch  to  the  ileocecal  fold,  the  '•  art'ere  recurrent  ileale"  of  Jonesco 
(Fig.  US  and  Types  I,  II,  III,  and  IV,  Figs.  122-138).  It  travels  upward  along 
the  free  margin  of  the  fold,  following  the  curve  described  by  the  latter  and 
giving  off  a  number  of  hue  brandies  along  its  course.  The  constant  presence 
of  this  artery  disproves  the  old  belief  that  this  fold  is  bloodless. 

Some  authors  state  that  they  have  observed  a  vascular  connection  between 


Fig.  126. — Type  I,  e.  One  Artery,  Supplying  only 
the  Appendix.  Origin:  Loop  of  Mesenteric 
Branch. 


Fig.  127. — Type  I,  f.     One  Artery.  Supplying  only 
the    Appendix.     Origin:    Upper    Branch   of 

Mesenteric. 


Fig.  128.— Type  II,  a.  Two  Arteries,  Supplying 
only  the  Appendix.  Origin:  Ileocolic  and 
Posterior  Ileocecal. 


Fig.  129. — Type  II.  b.  Two  Arteries.  Supplying 
only  the  Appendix.  Origin:  Mesenteric 
Branch  and  Posterior  Ileocecal. 


the  appendix  and  the  right  ovary  through  the  appendico-ovarian  ligament. 
This,  however,  is  not  often  found,  some  authors  having  failed  to  sec  it  even 
among  a  large  number  of  cases.  It  is  probably  merely  one  of  the  folds  formed 
in  the  peritoneal  reflection  of  the  mesappendix  over  the  posterior  abdominal 
wall,  and  supplied  with  the  usual  vessels  of  the  peritoneum,  but  it  is  not  likely 
that  the  appendix  itself  receives  in  this  manner  any  collateral  arterial  circula- 


Hit 


ANATOMY. 


tiini.  Then'  is,  however,  an  occasional  venous  anastomosis  between  the  ap- 
pendical  vein  and  the  ovarian  vein,  such  as  arc  found  between  any  neighboring 
organs  in  the  human  body.    The  fact  thai  the  circulation  of  both  the  ovary 

ami  the  appendix  is  completely  established  before  the  tw gans  come  into 

close  proximity  during  their  fetal  development,  is  an  additional  disproof  of 
t lit-  existence  of  an  anastomosing  arterial  branch. 


Fio.   130. — Type  II,  c.    Two  Arteries,  Supplying 
only  the  Appendix.     Origin  :  Posterior  Ileo- 


Fig.  131. — Type  II,  d.  Three  Arii  nn  s,  Si  PPL!  i%>. 
only  Tin:  Appendix.  Origin  :  One  from  1 1  i  o- 
colic  and  Two  prom  Pobteh Ileocecal. 


Fig.  132. — Type  III,  a.  One  Artery.  Origin:  Ileo- 
colic. Proximal  Branch  Supplies  a  Portion 
of  the  Cecum. 


Fig.  133. — Type  III,  h.     Two  Arteries.     Origin: 
Ileocolic    and    Posterior    Ileocecax.      The 

Proximal  Artery  Supplies  a  Portion  of  the 
I    i.'  DM. 


The  arrangement  of  the  main  arteries  of  the  appendix  may  be  classed  accord- 
ing to  four  types : 

Type  I  (Figs.  122-127).  A  single  appendical  artery  supplies  the  entire 
appendix,  but  no  portion  of  the  cecum,  with  the  exception  of  minute  anasto- 
mosing channels  between  them.  The  origin  of  this  artery  varies  considerably, 
bui  in  the  majority  of  cases  it  conies  from  the  ileocolic  direct.  To  this  type 
belong  about   one-third  of  the   cases  studied.     Some  of  the  many   variations 


TYPKS    OF    APPENDICAL    ARTERIES. 


If,.". 


of  this  type  are  shown  in  the  diagrams,  a  study  of  which  would  be  preferable 
to  a  long  description. 

Type  II  (Figs.  128-131)  includes  those  cases  where  there  is  more  than  one 
appendical  artery.  The  first  arises  as  in  Type  I  and  supplies  usually  the  distal 
four-fifths  of  the  organ,  while  the  remaining  proximal  portion  is  supplied  by 


Fig.  134. — Type  III,  c.  Two  Arteries.  Ohigin: 
Posterior  Ileocecal.  The  Proximal  Artery 
Supplies  a  Portion  of  the  Cecum. 


Fig.  135. — Type  III,  d.  Two  Arteries.  Oric;in: 
Ileocolic  and  Mesenteric  Loops.  The  Proxi- 
mal Artery  Supplies  a  Portion  op  tee  Cecum. 


Fig.  136. — TYPEllI.e.  Three  Arteries.  Origin: 
One  from  Mesenteric  Branch  or  Ileocolic 
and  Two  from  Posterior  Ileocecal.  The 
Proximal  Artery  Supplies  a  Portion  of  the 
Cecum. 


Fig.  137. — Type  IV.  a.  Two  Arteries,  Formim . 
a  Loop  in  the  Mesappendix  from  which  the 
Individual  Branches  Arise. 


a  second,  and  occasionally  a  third  appendical  artery  arising  from  the  posterior 
ileocecal.  It  is  very  seldom  that  any  communicating  branches  are  found 
between  t he  individual  arteries;  the  proximal  branch,  however,  often  sends 
small  twigs  into  the  adjacent  cecal  wall.  About  one-fourth  of  the  cases 
belong   to  this  type. 

Type   III    (Figs.    132-136)   includes   those   cases   where   a  single   or  several 


Dili 


ANATOMY. 


appendical  arteries  supply  both  the  appendix  and  a  considerable  portion  of  the 
cecum.  It  is  quite  common  to  find  an  artery  arising  from  the  posterior  cecal 
which  courses  in  the  mesappendix,  rinse  to  the  cecum,  and  which  is  directed 
toward  the  appendico-cecal  angle,  supplying  nol  only  the  proximal  portion  of 
the  appendix  but  several  square  inches  of  the  adjoining  portion  of  the  cecum. 
This  type  also  includes  one-fourth  of  the  cases.  An  operative  significance  of 
this  condition  lies  in  the  danger  of  cutting  off  the  blood-supply  to  a  portion  of 
the  cecum  by  ligating  the  proximal  appendical  artery. 

Type  IV  (Figs.  b!7  and  138)  is  nol  often  found  and  is  distinguished  by 
the  presence  of  loops  or  arches  between  the  main  arteries,  similar  to  those  in 
the  mesentery.  It  is  generally  associated  with  a  very  long  appendix.  Some- 
times there  is  but  one  such  arch,  but  two  and  occasionally  three  have  been 
observed.  From  the  lower  or  convex  side  of  the  arches  arise  the  appendical 
branches  proper,  usually  greater  in  number  here  than  in  the  previous  types. 


Fig.  138. — Type  IV,  b.  Three  Arteries,  the  Distal  Artery  Forming  a  Small  Loop,  while  the  Other 
Two  Form  a  Larger  Proximal  Loop.  The  Number  of  Individual  Branches  to  the  Appendix  is 
Increased. 

Jonesco  speaks  of  four  branches  or  sets  of  branches  coming  from  the  main 
appendical   artery:   (1)   to   the  posterior  wall  of  the  cecum:   (2)    to  the  cecc- 

appendical  angle;  (3)  to  the  appendix;  and  (4)  a  recurrent  branch  into  the  ileo- 
cecal fold,  the  " iMo-appendiculaire "  or  "artkre  recurrent  ileale."  According 
to  our  researches  these  four  branches  may  occur  in  one  case,  but  there  are 
a  great  number  of  instances  in  which  the  appendical  artery  gives  rise  merely 
t<»  the  recurrent  branch  into  the  ileocecal  fold,  and  the  cecum  and  ceco- 
appendical  angle  are  supplied  by  separate  branches  from  the  posterior  cecal 
arterv. 


THE  VEINS. 
Just  beneath  the  surface  epithelium,  between  the  glandular  openings,  the 
capillaries  are  seen  to  form  a  tortuous  plexus  (Tigs.  120  and  121),  which  drains 
through  short   venous  channels  running  parallel   to  one  another  anrl   to  the 


VEINS    OF   APPENDIX   AND    MESENTERIOLUM.  167 

glands  down  into  the  venous  network  of  the  muscularis  mucosa.  These  branches 
arc  larger  and  more  numerous  than  the  arterioles  of  the  mucosa.  On  their 
way  two  or  three  of  them  often  unite  to  form  a  larger  vessel.  In  the  sub- 
mucosa  the  veins  converge  in  bundles  to  be  gathered  into  a  few  large  channels, 
passing  in  the  submucosa  parallel  with  the  muscular  coats.  These  vessels  also 
receive  the  veins  of  the  follicles  and  those  of  the  submucosa  proper.  The 
latter  are  but  few  and  small. 

The  veins  of  the  muscular  coats  drain  partly  into  the  submucous  plexus, 
partly  into  the  superficial  plexus,  the  majority  selecting  the  latter  course.  The 
direction  of  the  small  venules  is  parallel  with  the  muscle  bundles  (Fig.  120). 
While  the  small  vessels  of  the  circular  coat  anastomose  to  seme  extent  with 
those  of  the  longitudinal  coat,  the  larger  veins  remain  independent  and  do 
not  communicate  until  they  reach  the  hilum.  The  veins  of  the  longitudinal 
coat  and  serosa  drain  either  in  large  tortuous  trunks  running  for  a  considerable 
distance  along  the  surface  of  the  appendix  before  turning  toward  the  hilum, 
or  they  drain  in  small  anil  short  channels  which  pass  directly  toward  the  hilum 
(Fig.  120).  The  degree  of  tortuosity  varies  with  the  degree  of  contraction  and 
relaxation  of  the  muscular  coats  of  the  appendix. 

The  union  between  the  different  venous  channels  of  the  superficial  and 
deep  systems  takes  place  either  close  to  the  mesappendical  border  or  somewhat 
further  up  in  the  mesappendix.  There  are  also  numerous  anastomoses  of  the 
larger  veins,  especially  in  the  submucous  plexus  (Fig.  120). 

Throughout  their  entire  course  inside  the  appendix  the  veins  in  general  lie 
central  to  the  arteries. 

In  the  mesappendix  the  veins  course  close  to  the  arteries,  the  latter  passing, 
as  a  rule,  nearer  to  the  mesappendical  border  (Fig.  118).  All  the  veins  collect 
into  one  large  vessel,  or  sometimes  into  two  or  three.  If  two  are  present,  the 
second  is  found  in  close  proximity  to  the  cecum.  The  main  appendical  vein 
occasionally  crosses  the  artery  in  the  middle  of  its  course,  and  in  the  vicinity 
of  the  tip  we  find  the  artery  nearer  the  free  border,  while  higher  up  the  vein 
occupies  that  position;  or  the  condition  may  be  reversed. 

In  the  ileocolic  angle,  about  3  cm.  from  the  intestine  (Figs.  118  and  139), 
the  appendical  vein  joins  the  veins  coming  from  the  adjacent  section  of  the 
intestine.  As  a  rule,  it  drains  first  into  the  posterior  ileocolic  branch,  although 
it  may  empty  into  any  vein  in  the  neighborhood,  as.  for  instance,  into  the 
mesenteric  vein,  coming  from  the  terminal  portion  of  the  ileum  (Fig.  118), 
or  into  the  anterior  ileocolic  branch  coming  up  in  the  ileocolic  fold.  United, 
these  branches  form  the  ileocolic  vein.  Running  upward,  it  joins  branches 
coming  from  the  ascending  colon  and  also  from  the  hepatic  flexure.  It  has 
now  become  the  right  colic  branch.  This  finally  drains  into  the  superior  mesen- 
teric vein  just  in  front  of  and  below  the  duodenum.  The  other  tributaries  of 
the  superior  mesenteric  vein  from  below  up  are:  on  the  left  side  the  veins  of 
the  small  intestine,  on   the   right  side   above  the   right  colic   the  pancreatico- 


IliS  ANATOMY. 

duodenal  branches.  Near  its  junction  with  the  inferior  mesenteric  vein  the 
superior  mesenteric  vein  receives  the  v.  gastro-epiploica  dextra.  The  other 
veins  of  the  stomach  and  pylorus,  as  well  as  the  splenic  vein,  drain  into  the 
inferior  mesenteric  or  into  the  portal  vein  just  before  its  entrance  into  the 
liver  i  Fig.   L39). 

Under  normal  conditions,  therefore,  the  blood  from  the  appendix  drains 
through  the  superior  mesenteric  and  portal  veins  into  the  liver;  i.e.,  from  the 
periphery  toward  the  centre.  If  the  centre  be  the  seat  of  an  obstruction,  the 
portal  system  being  blocked  up  by  a  pathological  process,  the  blood  seeks  other 
channels,  which  are  found  in  a  certain  number  of  preexisting  collateral  branches, 
as  a  rule  of  small  size,  which  establish  a  direct  communication  between  the 
portal  system  and  the  venae  cava;.  As  the  entire  portal  system  has  no  valves, 
the  Bow  of  blood  is  possible  in  any  direction.  It  depends  upon  the  seat  of 
obstruction  in  which  direction  the  blood  will  find  its  way.  In  doing  so  it  selects 
the  most  convenient  channels,  which  in  this  manner  become  dilated,  reaching 
in  certain  instances  considerable  dimensions. 

Such  veins  have  been  described  by  R.ETZIUS,  SAPPEY,  and  others,  and  through 
them  infections  of  appendical  origin  are  supposed  to  be  communicated  from 
the  portal  system  to  the  systemic,  to  enter  the  lungs  by  way  of  the  venae  cava? 
and  heart. 

These  venous  anastomoses  are  as  follows: 

1.  Communication  between  the  coronary  vein  of  the  stomach  (gastric) 
(Fig.  139),  the  veins  of  the  esophagus,  and  the  v.  azygos  major,  through  which 
the  blood  reaches  the  superior  vena  cava  and  the  heart.  There  is  also  often 
lound  an  anastomosis  between  the  coronary  and  the  diaphragmatic  veins, 
more  rarely  between  the  coronary  vein  of  the  stomach  and  of  the  gastro-epiploic 
with  the  renal  vein,  or  of  the  superior  mesenteric  with  the  left  renal  vein.  The 
vasa  brevia  passing  between  the  splenic  veins  and  the  stomach  occasionally 
anastomose  with  the  left  phrenic  vein. 

-.  There  is  a  communication  between  the  sigmoid  branch  of  the  left  colic 
vein  through  the  superior,  middle,  ami  inferior  hemorrhoidal  veins  into  the 
hypogastric,  iliac,  inferior  vena  cava,  and  heart;  or  from  the  sigmoid  flexure 
and  rectum  to  the  spermatic  or  ovarian  veins  (Retzius). 

•'!.  Communicating  branches  exist  between  the  veins  of  the  cecum,  colon, 
appendix,  and  the  adjacent  peritoneum  on  the  one  hand,  and  the  spermatic 
or  ovarian  on  the  other;  or  the  blood  drains  into  the  ilio-lumbar  vein  or  cir- 
CUmflexa  ilium  profunda,  and  through  them  into  the  inferior  vena  cava  and 
heart. 

Along    the    lateral    and    posterior   surfaces    of   the    cecum    and    the   adjacent 

portion  of  the  colon  there  are  numerous  small  vessels,  communicating  with 
the  venous  plexuses  of  the  outer  coats  of  the  intestine,  which  drain  into  the 
veins  of  the  posterior  abdominal  wall,  and  as  the  venous  network  of  the  ap- 
pendix and  cecum  communicate  freely,  the  blood  from  the  appendix  is  apt 


ro'I    3TIT  I  '     '        :  ■  i  Gof     ..if'f 

I 
I 

n 
o  aniov 
oini 


Fig.  139. — The  Veins  of  the  Appendix   and  their  Relation  to  the  Portal 

and  Systemic-  Circulation. 

Above  the  diaphragm  is  seep  the  heart,  imagined  transparent  so  as  to  show 
the  azygos  veins  and  their  communication  with  the  veins  of  the  esophagus. 

Lateral  to  the  cecum  are  a  number  of  subserous  branches,  wbich  establish  a 
communication  between  the  veins  of  the  ileocecal  region  on  the  one  hand,  and  the 
veins  in  the  iliac  fossa,  on  the  other;  i.e.,  between  the  portal  and  the  systemic 
circulation. 


Inters,  ■marn"1  ^<i 


IStl  i 


Fig.  139. 


VEINS  OF  KETZIUS  AND  SAPPET.  169 

to  select  these  channels  in  cases  of  obstruction  of  the  main  appendiceal,  ileo- 
colic, superior  mesenteric,  or  portal  veins  (Fig.  139). 

4.  There  are  occasional  anastomosing  twigs  between  the  veins  of  the  fixed 
portions  of  the  alimentary  canal;  viz.,  duodenum  (Retzius),  hepatic  flexure, 
and  splenic  flexure  of  the  colon,  as  well  as  of  those  of  the  pancreas  and  the 
veins  of  the  posterior  abdominal  wall. 

5.  The  veins  described  by  Sappey,  which  pass  from  the  adjacent  structures 
of  the  liver,  and  from  the  umbilical  region  between  the  folds  of  the  suspensory 
ligament  of  the  liver  to  drain  into  the  portal  system,  belong  also  in  this  group. 
While  the  former  branches  anastomose  above  with  the  phrenic  and  the  azygos 
veins,  the  latter  communicate  with  the  epigastric  veins  and  the  superficial 
veins  of  the  abdominal  wall,  internal  mammary,  etc.  The  largest  of  these 
branches  accompanies  the  round  ligament  of  the  liver  and  drains  into  the  left 
branch  of  the  portal  vein.  While  under  normal  conditions  the  flow  of  blood 
in  these  vessels  is  toward  the  liver,  in  cases  of  obstruction  of  the  portal  system 
the  direction  of  the  flow  is  reversed,  and  as  a  consequence  the  superficial  veins 
of  the  abdomen  and  thorax  become  much  distended,  some  of  the  main  channels 
attaining  the  size  of  the  little  finger. 

Adhesions  of  the  liver  to  the  diaphragm  are  also  often  carriers  of  new  vascular 
channels. 

The  veins  in  groups  1,  3,  and  4  are  most  apt  to  become  carriers  of  blood 
from  the  appendix  in  cases  of  obstruction  of  the  upper  portal  system. 

THE  LYMPHATICS  OF  THE  APPENDIX. 

General  Considerations. — Owing  to  the  valvular  character  of  the  lymphatic 
channels,  which,  like  the  veins,  do  not  permit  a  backward  flow  of  their  con- 
tents, the  lymphatics  must  be  injected  from  the  periphery  toward  the  centre. 
Infectious  matter  must  therefore  travel  in  a  similar  manner.  It  cannot  be 
carried  through  lymph  channels  from  one  part  of  the  appendix  to  another,  but 
must  pass  directly  into  the  mesappendix  and  thence  into  the  first  group 
i<\  glands. 

The  superficial  system  may  be  injected  by  inserting  the  needle  of  a  hypo- 
dermic syringe  just  beneath  the  peritoneum  and  introducing  an  aqueous  solution 
of  Prussian  blue,  to  which  a  few  drops  of  gelatin  may  be  added  to  advantage 
to  prevent  granulation  of  the  injection-mass.  India  ink  and  mercury  have 
also  been  used,  but  the  best  result-^  were  obtained  from  the  Prussian  blue. 
Only  a  limited  area,  varying  from  the  size  of  a  finger  nail  to  that  of  a  silver 
dollar,  or  perhaps  more,  can  be  completely  injected  through  any  one  such 
puncture.  The  larger  vessel  or  vessels  draining  the  area  are  always  injected 
with  it,  and  can  be  traced  with  ease  up  to  their  entrance  into  the  gland.  If 
it  is  impossible  to  obtain  an  injection  of  the  delicate  surface  capillaries  so  as 
to  render  the  larger  channels  visible  also,  the  latter  may  be  injected  directly 


170  ANATOMY. 

by  inserting  the  needle  into  the  opaque,  whitish-yellow  channels  following  the 
blood-vessels.  Tributary  vessels  are  not  injected  backward  from  these  large 
channels  on  account  of  the  valves  situated  at  the  mouths  of  the  smaller  vessels. 
Within  an  area  bordered  by  larger  collecting  channels,  all  the  delicate  surface 
capillaries  are  completely  injected  by  one  puncture,  hut  beyond  this  area  noi 
a  single  capillary  receives  t  lie  injection-mass.  This  demonstrates  the  existence  of 
valvular  structures  at  the  junction  between  the  capillaries  and  the  I irst  sys- 
tem of  collecting  vessels.  It  demonstrates  also  the  absence  of  valves  in  the 
capillaries.  A  locus  of  infection  inside  such  an  area  would  therefore  be 
practically  isolated  from  the  rest  of  the  appendix,  as  far  as  the  lymph  system 
is  concerned,  its  only  communication  with  the  first  glandular  station  being 
through  its  large  lymphatic  drainage  channel.  A  parallel  to  this  is  found  in 
the  capillary  venous  net  work  of  the  intestine,  similar  limited  areas  being  demon- 
strated by  injection.  A  dense  interlacing  network  of  capillary  vessels  (called 
"rete  mirabiU")  is  caused  by  the  sudden  breaking-up  of  larger  vessels. 

A  large  number  of  punctures  are  required  to  completely  inject  the  super- 
ficial system.  Some  of  the  deeper  lymphatics  are  often  injected  at  the  same 
time  through  channels  connecting  them  with  the  superficial  system.  The  in- 
jection may  also  be  made  from  the  mucous  surface,  but  with  far  less  success. 
The  network  at  the  base  of  the  mucous  glands  and  around  the  follicles  may 
thus  be  demonstrated,  and  a  few  of  the  tine  lymph  canaliculi  running  between 
the  glands. 

After  having  filled  all  the  surface  capillaries  of  the  desired  region,  a  certain 
number  of  large  lymphatic  channels  are  filled,  which  represent  the  drainage 
tubes  for  all  the  lymph  capillaries  contained  in  the  region.  They  are  seen  to 
converge  in  characteristic  fashion,  though  subject  to  great  variation,  until 
they  drain  into  smaller  or  larger  glands.  Small  glands  receive  from  one  to 
two  such  afferent  vessels,  while  the  larger  glands  receive  from  three  to  six  or 
more.  As  a  rule,  the  smaller  glands  are  situated  near  the  periphery,  the  larger 
ones  nearer  the  centre.  The  injection-mass  generally  stops  at  the  glands,  but 
the  study  can  be  made  still  more  complete  by  injecting  into  each  individual 
gland,  inserting  the  needle  into  the  peripheral  portion  receiving  the  afferent 
vessels  and  forcing  the  iiijection-mass  toward  the  centre.  It  is  taken  up  by 
the  efferent  vessels,  usually  less  in  number  than  the  afferent,  and  carried  to 
the  next  station  of  glands,  situated  higher  up — that  is.  more  centrally.  In 
this  manner  the  entire  lymphatic  system  of  the  appendiceal  and  ileocecal  region 
can  be  studied.  Throughout  their  entire  course  the  larger  lymphatics,  as  well 
as  the  glands,  are  generally  situated  along  the  course  of  the  blood-vessels. 
Should  the  injection-mass,  on  insertion  of  the  injection  needle,  pass  not  only 
into  the  lymphatics,  but  fill  the  vascular  system  at  the  same  time,  the  lymphatics 
are  easily  distinguished  by  their  beaded  structure  and  also  by  the  angular 
character  of  their  course. 

About    forty  specimens,   including  cecum,   ileum,   and  appendix,   were  in- 


./  I'l/.'lT:  /      in      "hi    1/  I     5ITIT    ':• 

it'Y.l    '-I" 
III)    viit   v 

ill  ni    1.; 
Tivnl  n  i > i r j :  iiiU'. 
Ij.i 

i.tl/ilill  vn't  vi 

[dm  iin  r  .11J  ■ 

•illol  nil   i 

I 


Fig.  140. — A  Reconstruction  op  the  Lymphatic  System  of  the  Appendix, 
Showing  the  Three  Strata  of  Lymphatics,  Magnified  20  Times. 
The  specimen  is  drawn  semitransparent  so  as  to  show  the  direction  of  the 
channels  in  the  depth.  I.  The  superficial  system  is  found  in  the  serosa.  It  con- 
sists of  a  delicate  anastomosing  network  just  heneath  the  peritoneum  and  a  layer 
of  larger  beaded  channels  immediately  heneath.  II.  The  middle  system,  situated 
between  the  muscular  coats  and  submucosa,  receives  comparatively  few  tributaries 
from  the  two  coats.  III.  The  deep  system,  forming  a  double  layer  at  the  base  <>( 
the  glands,  receives  the  delicate  finger-like  capillaries  of  the  mucosa  and  the  chan- 
nels coining  from  the  lymph  sinuses  around  the  follicles.  The  collecting  channels 
of  the  deep  system  drain  either  into  the  middle  system  or  through  the  submucosa 
toward  the  hilum. 


Muscular  coats 


Fig.  140. 


SUPERFICIAL   LYMPHATICS.  171 

jected  in  this  manner.  In  a  number  of  them  the  blood-vessels  were  also  injected 
— the  arteries  red.  the  veins  blue  while  the  lymphatics  were  tilled  with  lamp 
black,  by  which  method  specimens  of  singular  beauty  were  obtained.  For 
obvious  reasons  it  is  well  to  injeel  the  blood-vessels  first  and  the  lymphatics 
afterward. 

The  Lymph  Channels  of  the  Appendix  Proper. — The  lymphatic-  of  the 
appendix  consist  of  capillaries  and  collecting  channels,  the  greater  number  of 
the  latter  appearing  in  the  mesappendix. 

We  shall  first  describe  the  course  and  distribution  of  the  lymphatic  vessels 
of  the  appendix  proper,  and  then  follow  this  by  a  description  of  the  lymphatic 
channels  of  the  adjacent  region. 

The  lymphatics  of  the  appendix  may  be  divided  into  three  more  or  less 
distinct  systems  which  are  identified  with  the  coats  of  the  appendix, — the  super- 
ficial, the  middle,  and  the  deep.  Each  of  these  may  consist  of  two  strata  of 
vessels,  and  between  these  three  systems  there  are  channels  which  afford  com- 
munication. This  communication  must  be  either  insignificant  or  inconstant. 
as  we  were  not  often  able  to  inject  the  inner  layers  through  a  puncture  of  the 
outer,  and  vice  versa. 

The  superficial  system  (Fig.  140)  lies  in  the  serosa  and  con- 
sists of  two  layers,  or  strata;  f  i  r  s  t,  a  very  delicate  network  of  minute  anas- 
tomosing channels  lying  just  beneath  the  peritoneal  surface.  This  capillary 
network  consists  of  innumerable  anastomosing  lymph  channels  of  0.05  to  0.1 
mm.  in  width,  and  of  uneven  calibre,  having  irregular  oval  or  elongated  inter- 
spaces, which  measure  between  0.2  and  0.5  mm.  On  cross-section  they  are 
flattened.  There  are  no  valves  in  this  system  of  capillaries  except  at  the  places 
where  they  drain  into  the  s  e  c  o  n  d  stratum  of  the  superficial  layer,  which 
is  made  up  of  larger  collecting  channels,  showing  the  beaded  structure  char- 
acteristic of  lymphatics.  These  larger  collecting  channels  are  seen  in  a  fainter 
color  in  the  depth  between  the  network  of  the  superficial  system,  and  run  with 
preference  parallel  to  the  longitudinal  axis  of  the  appendix,  dividing  the  surface 
into  rectangular  areas.  Sometimes  one  of  these  channels  is  seen  to  run  along 
the  free  border  or  along  the  anterior  or  posterior  surface  of  the  appendix  for 
3  or  4  cm.,  or  for  almost  its  entire  length  (Figs.  141  and  142).  Their  arrange- 
ment corresponds  closely  to  that  of  the  lymphatics  of  the  ileum.  They  leave 
the  appendix  in  characteristic  manner,  each  larger  blood-vessel  at  the  hilum 
being  joined  by  two  lymphatics  coming  from  opposite  directions  (Fig.  141). 
Throughout  their  entire  course  in  the  mesappendix  the  blood-vessels  are  accom- 
panied by  two  or  more  such  beaded  lymphatic  channels  which  frequently 
anastomose  around  the  blood-vessels.  Exceptionally,  such  collecting  lymphatic 
channels  take  an  individual  course  in  the  mesappendix  and  are  seen  to  cross 
obliquely  the  interspaces  between  the  vascular  loops.  The  collecting  channels 
vary  in  width  between  0.2  and  1  mm.  Contrary  to  the  arrangement  of  the 
blood-vessels,  which,  as  a  rule,  have  one  common  trunk  in  the  mesappendix,  the 


171*  ANATOMY. 

lymphatics  do  not  unite  into  one  channel,  l>ui  approach  the  firsl  set  of  glands  in 
from  four  to  eight  or  more  separate  channels.  Concerning  these  glands  we 
shall  speak  after  having  first  described  the  rest  of  the  lymphatics  within  the 
appendix. 

The  middle  system  (Fig.  140)  is  situated  in  the  submucosa, 
between  Lhal  coal  and  the  circular  muscle. 

An  injection  will  nol  show  these  deeper  lymphatic  vessels  on  an  inspection 
of  the  surface,  as  only  the  above-described  superficial  system  is  visible  from 
the  outside.  It  is  not  until  microscopic  sections  have  been  made  or  the  surface 
layer  peeled  off,  the  rest  of  the  injected  appendix  being  cleared  in  creosote  or 
glycerin,  that  the  middle  system  can  be  demonstrated.  This  system  is  of  con- 
siderable significance  in  stripping  out  the  inner  portion  of  the  appendix  from  its 
muscular  envelopment.  The  lymphatic  channels  are  so  close  together,  and  have 
such  loose  and  delicate  walls,  that  separation  of  the  layers  in  the  fresh  specimen 
appears  easier  in  this  region  than  elsewhere.  This  question  is  dealt  with  more 
fully  in  the  description  of  the  muscular  coats  in  the  section  on  "Structure  of 
the  Appendix," Chap.  VI,  p.  L39. 

These  tun  systems,  the  superficial  system  in  the  serosa,  and  the  middle 
system  lying  between  the  muscularis  and  the  submucosa,  enclose  the  muscular 

coats,  whose  few  lymphatics  may  drain  In  either  system.  The  other  channels 
seen  in  the  submucosa,  strictly  speaking,  belong  to  the  third  or  deep  system. 
They  are  large  headed  trunks,  dilated  in  places,  which  pass  in  an  irregular 
fashion  in  all  directions,  preferably,  however,  toward  the  hilum.  where  they 
either  anastomose  with  the  other  collecting  system-  or  emerge  as  independent 
channels.  These  vessels  may  be  quite  distinct  from  the  layer  of  lymphatics 
lying  between  the  submucous  and  muscular  coats,  or  the  two  may  he  com- 
bined into  a  single  system.  All  the  \  easels  of  the  middle  system,  as  well  as 
those  connecting  them  with  the  superficial  and  deep  systems,  possess  well- 
marked  valves. 

The  deep  system  consists  of  a  very  complex  anastomosing  network, 
the  central  layer  of  which  lies  between  the  mucosa  and  the  muscularis  mucosa'. 
Into  this  plexus  the  delicate  end-branches  coming  out  of  the  mucosa  are  seen 
to  drain.  There  is  a  second  more  peripheral  network,  the  larger  headed  chan- 
nels of  which  course  parallel  to  the  central  system  (Fig.  140).  Between  the 
two  lies  the  muscularis  mucosa',  not  well  developed, however,  in  every  instance. 

Beginning  at  the  inner  surface — that  is.  at  the  glands  of  I.ieherkiihn — and 
following  the  lymphatics  up  to  the  larger  collecting  channels,  we  must  first 
describe  the  delicate  finger-like  terminal  branches  which  drain  the  mucous  mem- 
brane. According  to  our  present  knowledge,  they  are  blind  channels  which  run 
more  or  less  parallel  to  and  between  the  glands  of  Lieberkuhn.  At  different  places 
between  the  surface  and  the  base  of  the  gland-  they  are  seen  to  unite  with 
ueighboring  channels.  However,  they  not  infrequently  remain  single.  In 
their  course  they  are  enveloped  in  a  network  of  delicate  blood  capillaries. 


LYMPH    SUPPLY    OF    FOLLICLES.  173 

The  lymphatics  of  the  follicles  seem  to  be  confined  to  their  surfaces,  which 
they  are  seen  to  envelop  in  a  dense  network.  This  system  appears  continuous, 
perhaps  identical,  with  that  of  the  base  of  the  glands.  This  network,  which 
is  very  well  seen  in  Fig.  140,  at  the  left  of  the  picture,  where  the  mucous  mem- 
brane and  follicles  have  been  removed,  is  somewhat  more  delicate  than  the 
anastomosing  capillaries  of  the  peritoneal  surface.  Its  meshes  are  less  elon- 
gated, and  pass  without  regularity  in  any  direction.  On  cross-section  it  is 
seen  that  this  network  drains  by  mean-  of  short  channels,  penetrating  the  mus- 
cularis  mucosae,  into  the  more  peripherally  located  collecting  system.  This 
Bystem  has  larger  beaded  channels,  and  the  lymph  sinuses  around  the  follicles 
drain  either  into  them,  or  directly  into  the  submucous  trunks.  Concerning 
these  lymph  sinuses  Lockwood  has  said  the  following:  "Around  the  follicles 
there  exists  a  large  lymphatic  sinus.  This  sinus  surrounds  the  basal  half  of 
the  follicle  and  is  called  'the  lymphatic  sinus,  or  the  basal  lymphatic  sinus,  of 
the  follicle."  In  cases  of  appendicitis  this  sinus  may  extend  farther  and  com- 
pletely surround  the  follicle.  At  other  times  it  is  obliterated  either  by  com- 
pression or  by  the  accumulation  in  its  interior  of  inflammatory  corpuscles. 
These  lymphatic  sinuses  of  the  follicles  then  empty  into  the  lymphatics  of  the 
submucosa."  As  was  said  above,  the  deep  system  either  drains  downward 
into  the  middle  system,  or  it  has  its  own  beaded  collecting  channels,  which 
l>a<s  through  the  submucosa  and  converge  toward  the  hilum  where  they  either 
join  the  other  collecting  channels  or  pass  as  independent  channels  through 
the  mesappendix  up  into  the  gland.  Along  the  hilum  of  the  appendix  there 
are  a  number  of  points  where  the  blood-vessels  and  lymph  channels  emerge  to 
pass  upward  into  the  mesappendix.  At  these  points  the  muscular  coats  are 
interrupted  'Fig.  114).  and  the  submucous  and  subperitoneal  tissues  become 
continuous  with  one  another.  Through  these  so-called  muscular  hiatuses  infec- 
tion is  more  likely  to  travel  from  the  mucosa  of  the  appendix  to  the  mes- 
appendix than  in  any  other  way. 

The  General  Character  of  the  Surface  Lymphatics  of  the  Ileocecal 
Region. — The  general  character  of  the  lymphatics  of  the  appendix,  that  is, 
their  relation  to  one  another  and  to  the  adjacent  portion  of  the  cecum  and 
more  remotely  the  ileum  and  colon,  is  of  sufficient  importance  to  warrant  a 
somewhat  detailed  description. 

While  the  lymphatic  drainage  of  the  appendix  is  mainly  through  the  mes- 
appendix into  the  ileocolic  chain  of  glands,  there  are,  as  will  be  seen  later. 
occasionally  some  small  channels  draining  the  proximal  appendical  portion  into 
the  cecal  trunks.  Along  the  line  of  peritoneal  reflection  of  the  cecum  over 
the  abdominal  wall,  delicate  anastomosing  lymph  channels  can  be  demonstrated 
between  the  lymphatics  of  the  cecal  serosa  and  those  of  the  adjacent  parietal 
peritoneum.  This  condition  might  be  spoken  of  as  a  lymphatic  communication, 
though  of  an  insignificant  character,  between  the  appendix  and  cecum  on  the 
one  hand,  and  the  iliac  and  lumbar  glands  on  the  other.     A  similar  communi- 


\,  I  ANATOMY. 

cation  also  exists  between  the  blood-vessels  of  the  cecum  and  the  systemic 
circulation  (sec  section  on  "Veins,"  p.  166).  The  lymphatic  communication 
between  appendix  and  ovary,  as  claimed  by  Clado  and  Lafforgi  e,  belongs 
probably  in  this  class.  While  the  direction  of  the  surface  lymphatics  of  the 
appendix  is,  in  general,  parallel  to  its  axis,  resembling  the  surface  lymphatics  of 
the  small  intestine,  those  of  the  cecum  and  colon  appear  to  be  arranged  without 
such  definite  reference  to  the  direction  of  the  intestine.  This  peculiar  arrange- 
ment of  the  lymphatics  of  the  appendix  has  its  cause,  no  doubt,  in  the  fact 
that  the  longitudinal  coat  is  more  strongly  developed  than  that  of  the  cecum, 
where  the  longitudinal  fibres  are  confined  more  or  less  to  the  longitudinal  mus- 
cular bands.  The  larger  collecting  channels  pass  transversely  around  the 
cecum  and  colon,  being  confined  more  or  less  to  the  depressions.  On  crossing 
the  longitudinal  muscular  bands  the  lymphatics  pass  beneath  them.  Here,  as 
in  the  appendix,  the  lymphatics  usually  pass  on  either  side  of  the  blood-vessels. 
The  general  character  of  these  lymphatics  is  best  understood  by  studying  Figs. 
141  and  142. 

On  examination  of  Figs.  1  11  and  142  three  distinct  groups  of  channels  are 
easily  recognized : 

1.  The  anterior  cecal  trunks,  converging  from  the  cecal  pouches  toward  the 
ileocolic  fold,  where  they  generally  pass  through  one  or  more  isolated  glands 
before  reaching  the  ileocolic  group  (Fig.  141). 

i'.  The  posterior  cecal  trunks,  converging  from  the  posterior  cecal  pouches 
toward  the  ileocolic  angle.  They  also  pass  through  a  few  isolated  glands  (three 
to  six)  before  reaching  the  ileocolic  group  (Fig.  1  12), 

3.  The  appendical  trunks  (three  to  six  in  number),  converging  in  the  mes- 
appendix  in  an  upward  direction.  As  figure  1 4'-'  shows,  these  channels  are  in 
character  similar  to  the  posterior  cecal  trunks,  the  only  difference  being  the 
fact  that  they  usually  do  not  pass  through  isolated  glands  on  their  way  up  to 
the  ileocolic  glandular  group.  The  proximal  lymph  channel  of  the  appendix 
receives  oi r  two  small  tributaries  passing  from  the  ileum  through  the  ileo- 
cecal fold  (figs.   141  and   143-146). 

The  I.  y  mphatics  of  the  Appendico-  c  e  c  al  J  u  n  c  t  i  o  n. 
— The  development  of  the  appendix  out  of  the  cecum  by  a  process  of  nan-owing 
down,  or,  more  correctly  speaking,  a  cessation  of  development  of  the  terminal 
portion  at  a  varying  point  from  the  ileocecal  valve,  teaches  us  why  there  is 
no  marked  line  of  anatomical  division  between  the  lymph  system  of  the  two 
organs.  The  same  is  true  of  their  vascular  systems.  Tims,  the  proximal 
portion  of  the  appendix  may  have  its  individual  lymph  channels  passing  up 
in  the  mesappendix,  while  the  adjoining  cecal  region  may  drain  upward  in 
separate  cecal  channels.  On  the  other  hand,  it  has  been  found  that  the  prox- 
imal portion  of  the  appendix  may  drain  into  the  cecal  lymphatic  system,  and 
also,  which  seems  more  common,  the  opposite  condition  is  noted,  viz.,  the 
lower  portion  of  the  cecum  draining  into  the  lymphatic  channels  of  the  appendix 
(Fie.  141). 


Fig.  141. — The  Lymphatic  Circulation  of  the  Ileocecal,  Region.  Anterior  View. 
For  the  sake  of  clearness  only  the  larger  collecting  channels  are  drawn.  The  main  arteries  are  inserted 
as  white  channels  in  order  to  illustrate  their  relation  to  the  lymphatics.  The  lymphatics  of  the  appendix  collect 
into  two  main  channels  in  the  mesappendix,  winch  pas-  parallel  to  one  another  and  to  the  artery.  They  drain 
into  two  glands  situated  about  3  Cm.  above  the  ileum.  These  glands  are  found  in  the  median  portion  of  the 
ileocolic  chain  of  elands. 


175 


Fig.  142. — Posterior  View  of  the  Ileocecal  Region,  Showing  the  Main  Lymph-trunks  and  their  Rela- 
tion to  the   Ileocolic  Chain  of  Glands. 

The  large  size  of  the  glands  in  this  and  in  the  previous  picture  is  due  to  their  distention  with  injection  mass. 
The  glands  are  confined  to  the  extraperitoneal  portion  of  the  mesocolon  and  intestine,  the  line  of  peritoneal  re- 
flection having  a  V-shaped  outline,  the  apex  being  in  the  ileocolic  angle. 

The  lymphatics  of  the  appendix  in  this  case  are  more  numerous  than  those  in  Fig.  Ml.  They  drain  into 
three  glands.  The  |owe>t  of  these  three  receives  besides  the  proximal  appendical  channels  a  few  trunk.-  coming 
from  the  distal  portion  of  the  cecum.  This  gland  might,  therefore,  be  termed  ceco-appendical.  The  lowesl 
gland  of  the  chain,  situated  just  nver  the  posterior  cecal  pouch,  ha-  been  described  a-  Clado'a  gland  and  called 
appendical  gland,  as  in  the  state  of  contraction  of  the  bowel  it  may  become  lodged  m  the  mesappendix.  However. 
as  this  injection  shows,  this  gland,  if  present,  receives  lymph  from  the  cecum  and  not  from  the  appendix.  In 
a  very  few  instances  it  received  a  small  tributary  from  the  ceco-appendical  angle.      (See  Type  IV,  Fig.  140.  A.) 


12 


TYPES    OF    LYMPHATIC    CIRCULATION. 


179 


Fig.    143. — Lymphatic  Circulation-.     Type  I. 


Fig.   144. — Lymphatic  Circulation.     Type  II. 


ISO  ANATOMY. 

V  a  rial  i  o  n  a  of  the  1.  y  m  ph  a  t  i  c  C i r  cula ti  o  a  . — The  ar- 
rangement of  the  lymphatic  system  is  subjeel  to  innumerable  individual  changes, 
do  two  specimens  ever  showing  the  same  disposition.  Nevertheless,  there  are 
four  types  according  to  which  practically  all  forms  may  he  classified.  These 
are  pictured  in  Figs.  14.'>,  144.  145,  and  146.  The  arrows  indicate  the  flow 
of  the  lymph. 

Type  I.  Fig.   1  13. 

Anterior  View. — The  median  cecal  and  colic  pouches  drain  upward  and 
medianward  by  way  of  the  ileocolic  fold;  traversing  a  few  isolated  glands, 

the  lateral  pouches  drain  toward  the  posterior  side.  The  appendical  collecting 
tubes,  being  only  few  in  Dumber,  receive  lymphatics  from  the  entire  appendix 
and  a  small  tributary  from  the  ileum  passing  through  the  ileocecal  fold.  The 
latter  is  constant  in  all  types.  The  lirst  glandular  station  for  the  appendical 
lymphatics  is  well  up  in  the  ileocolic  angle.  The  two  appendical  glands  are 
situated  in  the  mesial  portion  of  the  glandular  group. 

Type  II,    Fig.    111. 

Anterior  View. — The  median  as  well  as  the  lateral  colic  and  cecal  pouches 

drain    anteriorly,    likewise    the    anterior    face    of    the    ileum.       The    ileocolic 

fold  contains  three  small  glands,  toward  which  the  collecting  channels  of  the 

neighboring  region  converge;  the  efferent   tubes  pass  from  these  glands  upward 

by  way  of  the  il solic  fold.     While  the  proximal  sixth  of  the  appendix  drains 

toward  the  cecum,  the  rest  sends  its  lymphatics  toward  the  free  mesappendical 
border,  along  which  the  collecting  tubes  course.  As  in  Type  I,  the  first  glandular 
station  is  well  above  the  ileum;  there  are  two  small  appendical  glands  which 
form  the  lower  portion  of  the  ileocolic  group. 

Type  III.   big.    145. 
Anterior    View. — The    median    cecal    pouch    drains    partly    anteriorly    by 
way  of   the   ileocolic    fold,    partly  posteriorly  by  way   of    the   mesappendix. 

The  lateral  pouches  drain  posteriorly.  There  are  no  isolated  anterior  colic 
glands.  The  proximal  sixth  of  the  appendix  and  the  adjacent  cecal  region 
drain  in  one  common  trunk  which  runs  parallel  to  the  lowest  cecal  trunk,  the 
latter  receiving  the  ileal  tributary  coming  through  the  ileocecal  fold.  These 
two  channels  run  into  a  gland  situated  just  above  and  behind  the  ileocolic 
junction,  partly  hidden  in  the  ileocolic  fossa.  The  rest  of  the  appendical  lym- 
phatics are  arranged  in  a  similar  maimer  to  those  in  Types  I  and   II. 

Type  IV,   Fig.   140. 
Anterior    View. — The    median    and    lateral    colic    and   cecal    pouches,  ex- 
cepting    the    lower    portion,  drain    by  way  of    the  ileocolic  fold,  traversing  an 
isolated   gland  ventral  to  the  ileocolic  junction.     The  appendical  lymphatics 


TYPES    OF    LYMPHATIC    CIRCULATION'. 


181 


Fig.   145. — Lymphatic  Circulation.     Type  III. 


Fig.   146.— Lymphatic  Circulation.     Typk  IV. 


182  ANATOMY. 

drain  in  three  main  groups,  each  terminating  in  one  or  two  separate  glands, 
the  distal  lymphatics  traversing  the  Longest  distance. 

The  proximal  appendical  channel  receives  a  tributary  from  the 
adjacent   portion  of  the  cecum  and  terminates  in  a  small  gland  situated  in  the 

tnesappendix  in  the  inferior  ileocecal  angle  (A).  This  gland,  however,  receives 
a  tmt  her  tributary,  much  larger  than  the  appendical,  coming  from  the  cecal  pouch. 

CLADO  and  others  have  called  this  gland  appendical,  owing  to  its  position  in 
the  mesappendix;  this  seems  an  error,  as  it  is  found  in  only  few  instances,  and 
even  then  its  connection  with  the  appendix  is  but  insignificant  as  compared 
with  that  of  the  cecum.  The  m  iddl  e  group  of  appendical  lymphatics 
receives  the  tributary  passing  down  through  the  ileocecal  fold.  Its  glandular 
terminus  i<  in  the  mesentery  just  above  the  ileum.  The  d  i  s  t  a  1  appendical 
channels  are  the  largest  in  size;  they  follow  the  course  of  the  main  appen- 
dical artery  along  the  free  border  of  the  mesappendix  and  terminate  in  two 
glands  situated  in  the  lower  median  portion  of  the  ileocolic  group  of  lymph 
glands. 

A  study  of  these  four  figures  demonstrates  that  the  types  of  lymphatic 
circulation  of  the  ileocolic  region  have  the  following  points  in  common: 

a  I  The  upper  cecal  and  colic  surfaces  drain. — anteriorly,  by  way  of  the  ileo- 
colic fold,  with  or  without  glandular  sub-stations  in  the  fold;  posteriorly,  con- 
verging toward  the  ileocolic  chains  without  gathering  in  a  bundle  like  the 
anterior  trunks.  There  are  more  posterior  glandular  suli-stations  than  anterior. 
The  lower  portion  of  the  cecum  may  drain  either  in  an  anterior  direction  (ileo- 
colic fold)  or  in  a  posterior  direction  (mesappendix). 

(b)  The  lymphatics  of  the  terminal  portion  of  the  ileum  drain. — anteriorly, 
by  way  of  the  ileocolic  fold;  posteriorly,  directly  into  the  ileocolic  glands. 

(c)  The  ileocecal  fold  is  the  carrier  of  one  or  two  small  lymph  channels 
connecting  the  lymph  vessels  of  the  lower  border  of  the  ileum  with  the  mes- 
appendical  trunks. 

ill  The  distal  five-sixths  of  the  appendix,  or  the  entire  appendix,  has 
its  individual  lymphatic  drainage  by  way  of  the  mesappendix.  The  proximal 
portion  of  the  appendix  rarely  drains  into  the  cecal  trunk-. 

e)  The  collecting  channels,  running  in  pairs,  form  one  to  three  separate 
bundles,  usually  only  one.  passing  along  the  free  border  of  the  mesappendix.  If 
there  are  more  than  one.  the  others  run  at  fairly  regular  intervals  between  the 
main  bundle  anil  the  cecum. 

ff)  In  the  overwhelming  majority  of  cases  the  first  glandular  station  of 
the  appendical  lymphatics  is  in  the  mesentery  of  the  ileocolic  angle,  from  1 
to  3  cm.  above  the  ileum.  The  appendical  glands  are  rarely  more  than  two 
in  number  and  are  generally  situated  at  the  lower  median  side  of  the  ileocolic 
chain  of  glands. 

Glandular  sub-stations  or  isolated  glands  in  the  mesappendix  or  in  the 
appendico-cecal  angle  are  rare. 


GLANDS.  183 

The     Collecting     Channels     in     the     Mesappendix . — 

These  beaded  vessels  pass  on  either  side  of  the  blood-vessels,  in  an  upward 
direction;  an  isolated  channel  may.  however,  occasionally  seek  an  individual 
course  (Fig.  141).  All  converge  toward  the  appendical  glands  and  it  is  the 
position  of  these  which  determines  the  length  and  direction  of  the  collecting 
channels.  Those  near  the  cecum  arc  shortest,  the  distal  channels  longest. 
Their  length  varies  from  3  to  15  cm.,  the  most  frequent  length  being  about 
10  cm.  Delicate  anastomosing  branches  pass  between  the  parallel  trunks,  thus 
enveloping  the  blood-vessels  in  a  dense  lymphatic  network.  Minute  tributaries 
of  mesappendicaJ  origin  also  empty  into  the  collecting  channels. 

The  Glands  of  the  Ileocecal  Region. — Like  the  lymph  vessels  themselves, 
the  glands  are  also  subject  to  great  variation,  both  as  to  size  and  position.  All 
cases,  however,  have  some  points  in  common  which  permit  a  general  description. 

In  the  ileocolic  angle  is  a  chain-like  group  of  glands,  greater  in  number  than 
eleswhere  in  the  lower  portion  of  the  mesentery.  The  direction  of  the  chain 
is  obliquely  upward  and  inward,  beginning  at  the  region  of  the  ileocolic  junction. 
The  individual  glands  are  grouped  around  the  ileocolic  vessels  and  are  either 
packed  closely  together,  forming  clusters  around  the  vascular  bifurcations,  or 
are  scattered  somewhat  more  uniformly  over  the  area  marked  by  the  ileocolic 
angle,  in  which  case,  however,  they  still  remain  near  some  blood-vessel.  The 
larger  of  these  glands,  measuring  from  8  X  10  to  12  X  16  mm.,  with  a  few 
exceptions  are  near  the  main  vascular  trunks,  the  smallest  near  the  periphery. 
These  latter  will  be  designated  and  described  as  isolated  glands. 

The  individual  glands  of  the  ileocolic  chain  are  connected  with  one  another 
by  lymph  channels,  which  increase  in  calibre  as  they  emerge  from  the  glands. 
Their  farther  course  is  along  the  mesenteric  vessels,  where  they  are  joined  by 
tributaries  from  the  small  intestine,  large  intestine,  and  celiac  glands.  They 
drain  into  the  receptaculum  chyli.  the  upper  continuation  of  which,  the  thoracic 
duct,  passes  behind  the  aorta  through  the  diaphragm  and  empties,  ultimately, 
into  the  left  subclavian  vein. 

Isolated  C  o  lie  an  d  Cecal  G  1  a  n  d  s  . — If  present,  they  appear 
as  relays  placed  along  the  course  of  the  lymphatics  (Tigs.  141  and  Hi').  They 
are  the  first  to  receive  the  lymph,  though  collecting  channels  are  not  infre- 
quently seen  to  run  past  them  to  enter  some  gland  situated  more  centrally. 
Isolated  glands  are  generally  small  in  size,  measuring  from  1'  X  -  to  2  X  3 
mm.,  and  situated  in  the  depressions  between  the  pouches  of  the  colon.  They 
seem  to  be  more  frequent  and  smaller  on  the  posterior  than  on  the  anterior 
surface  of  the  large  intestine,  the  latter  measuring  from  4  X  0  to  5  X  7  mm. 

On  the  anterior  surface  isolated  glands  are  found  in  the  ileocolic  fold  and 
along  the  mesenteric  border  of  the  colon  |  Fig.  141).  The  lowermost  of  these  is 
met  with  in  quite  a  number  of  instances  lying  ventral  to  the  ileocecal  valve 
and  just  lateral  to  the  ileocolic  fold  (Figs.  143.  144.  and  146;  Types  I.  II.  and 
IV).     Occasionally,  it  has  one  or  two  daughter  glands.     This  gland,  or  glands, 


IS  I  VNATOMY. 

receive  lymphatics  from  a  part  of,  i>r  the  entire  anterior  surface  of  the  cecum, 
never  from  the  appendix.  Below  this  we  have  found  no  glands  on  the  anterior 
surface,  although  some  writers  claim  to  have  seen  them. 

On  the  posterior  surface  isolated  glands,  as  was  said  above,  are  more  numer- 
ous, from  1  I"  15  being  distributed  over  about  1()  cm.  of  the  large  intestine. 
The  lowermost  of  these  glands  is  found  at  varying  levels.  It  may  reach  the 
appendico-cecal  angle,  hut  is  generally  found  some  distance  above,  lying  close 
againsi  the  cecum  (Figs.  142  and  146,  A).  This  corresponds  to  the  gland 
which  ClADO  called  the  "appendicular  gland,"  and  which  he  described  as  follows: 
"At  the  base  of  the  mesappendix  in  the  angle  which  separates  the  appendix 
and  the  cecum  from  the  small  intestine,  there  lies  a  gland,  the  appendicular 
gland.  It  is  situated  between  the  two  layers  of  the  mesappendix  and  may 
attain  a  considerable  size.  The  gland  is  constant,  but  it  is  sometimes  displaced 
and  encroaches  upon  the  terminal  portion  of  the  mesentery,  when  it  may  be 
considered  as  the  last  of  the  mesenteric  glands."  In  the  large  herbivorous 
animals,  which  have  a  long  appendix-like  cecum,  this  gland  is  very  well  de- 
veloped and  receives  lymphatics  of  the  cecum  independently  of  the  mesenteric 
glands.  However,  since  this  gland  in  the  human  subject  receives  the  lymphatics 
from  the  lower  extremity  of  the  posterior  surface  of  the  cecum,  and  only  very 
rarely  a  small  tributary  from  the  proximal  portion  of  the  appendix,  we  think 
the  term  "appendicular"  a  misnomer  for  this  gland.  It  is  sometimes  repre- 
sented by  a  number  of  glands  forming  a  little  group  on  the  posterior  surface  of 
the  cecum  (the  ceco-appendicular  group  of  TlXIEB  and  VlANNEY).  They  are 
continuous  with  the  ileocolic  chain  of  glands  and  often  lie  entirely  in  the  mesen- 
tery as  long  as  the  intestines  are  in  situ,  removal  and  distention  of  the  cecum, 
preparatory  to  the  injection,  drawing  them  over  onto  the  surface  of  the  cecum. 
The  other  isolated  glands  are  found  scattered  over  the  posterior  surface  of  the 
colon  and  along  the  mesocolic  border.  They  hug  the  blood-vessels  and  are 
situated,  as  a  rule,  in  the  grooves  between  the  colic  pouches  (Fig.   112). 

The  Glands  of  t  h  e  A  p  p  e  nd  ix  . — The  glands  of  the  appendix 
receive  the  lymph  conveyed  to  them  through  the  collecting  channels  of  the 
mesappendix  and  communicate  it  to  the  next  glands  in  the  chain.  They  serve 
merely  as  an  intermediary  between  the  appendical  lymphatics  and  the 
ileocolic   chain  of  glands. 

The  position  of  the  appendical  glands  has  been  described  in  many  different 
ways,  the  literature  containing  the  most  contradictory  statements. 

This  is  not  surprising,  as  the  arrangement  of  the  glands  is  so  variable,  hardly 
any  two  specimens  ever  being  alike.  It  may,  therefore,  be  of  value  to  give 
some  of  the  principal  descriptions. 

Before  1880  little  was  known  about  the  lymphatic  circulation  of  the  ap- 
pendix. Clado  in  lN'12  observed  three  or  four  channels  which  traveled  toward 
a  gland    in    the   ceco-appendieal   angle,    since   known   as   Clado 's   gland.     As 


GLANDS    IN    MESAPPENDIX.  185 

was  said  above,  this  gland  is  inconstant,  and  if  found,  receives  more  cecal  channels 
than  appendical. 

The  first  fairly  accurate  description  and  statistics  of  the  appendical  glands 
are  given  by  Lafforgue,  and  by  Tixier  and  Yianney. 

Lafforgue  in  1S93  stated  that  in  three-fourths  of  his  cases  there  was  no 
gland  in  the  mesappendix,  all  the  appendical  lymphatics  emptying  directly 
into  the  mesenteric  glands.  In  the  other  fourth  he  found  glands  within  the 
mesappendix,  viz. : 


In 

18.5 

per 

cent. 

,  one 

gland. 

it 

3.5 

tt 

two 

glands. 

tt 

2 

tt 

three  glands. 

a 

3 

a 

foui 

■  glands. 

are 

2 

glands, 

a 

3 

u 

a 

4 

tt 

tt 

5 

a 

tt 

6 

a 

tt 

7 

a 

According  to  Tixier  and  Vianney,  in  one-half  of  the  cases  there  are  no 
glands  in  the  mesappendix,  while  in : 

20  per  cent,  there  is     1  gland. 
10 

S 

4 

2         " 

2         " 

2 

o  a  tt  a        o  il 

Tixier  and  Yianney  have  classified  these  mesappendical  glands  into  three 
sets:  I.  Ilco-appendical,  II.  Appendical,  and  III.  Ceco-appendical,  according 
to  whether  they  are  behind  the  ileum,  near  the  hilum  of  the  appendix,  or  in 
the  ceco-appendical  angle.  The  latter  are  continuous  with  the  ileocolic  chain 
of  glands. 

Auguy  says  that  while  the  glands  may  be  found  throughout  the  entire 
extent  of  the  mesappendix,  they  are  more  apt  to  be  grouped  at  its  base, i.e., 
the  region  where  it  becomes  continuous  with  the  mesentery  (thirty  per  cent, 
of  his  cases). 

Poirier  and  Cuneo  give  a  similar  description  of  the  glands  in  the  mes- 
appendix. There  are  three  groups :  I,  Retro-ileal  (most  frequent);  II,  Sub-ileal; 
and  III,  Juxta-cecal  (the  two  latter  groups  being  present  only  in  few  instances). 

AYhile  we  have  occasionally  seen  appendical  glands  in  the  retro-ileal  area 
of  the  mesappendix — i.  e.,  in  those  few  cases  where  the  peritoneal  reflection 
of  the  mesappendix  was  below  the  ileum — in  the  overwhelming  majority  of 
our  cases  the  appendical  glands  were  found  some  distance  above  the  ileum 
in  the  ileocolic  angle,  as  a  rule  to  the  left  of  the  ileocolic  vessels,  near  the  point 
of  origin  of  the  appendical  artery.     There  were  generally  not  more  than  two 


186  ANATOMY. 

glands  of  medium  size  (4  to  6  nun. )  forming  a  pari  of  the  ileocolic  chain.  Longer 
appendices  may  have  three  to  five  glands  whose  arrangement  corresponds  more 
or  less  to  that  of  the  origin  of  the  appendical  arteries,  of  which  several  may 
lie  present.     In  such  eases  the  appendical  glands  form  two  or  three  groups, 

lying  some  distance  apart    from  one  another  and  also  apart   from  the  ileocolic 

chain,  each  receiving  the  lymphatics  from  a  separate  section  of  the  appendix, 
the  proximal  portion  of  the  appendix  having  the  lowest,  the  distal  the  highest 
gland  or  glands.  This  may  account  for  the  statement  of  Tixieh  and  Vianney, 
that  "the  appendix,  an  organ  of  double  insertion,  cecal  by  its  rout  proper  and 
ileal  by  its  mesentery,  parts  its  lymphatic  circulation  into  two  main  currents,  one 
of  them  being  directed  toward  the  cecum  and  the  mesocolic  glands,  the  other 
toward  the  ileum  and  the  mesenteric  glands." 

(!  lands  in  t  h  e  M  e  s  a  p  pend  ix  . — As  was  said  above,  Lafforgue 
(1893)  reported  the  occasional  presence  of  a  large  number  of  glands  in  the 
cellular  tissue  of  the  mesappeiidix.  AlJGUY  states  that  glands,  from  1  to  8 
in  number,  may  he  grouped  throughout  the  entire  extent  of  the  mesappendix, 
but  are  generally  situated  along  the  hilum  of  the  appendix.  Three  times  he 
found  a  single  gland  in  the  middle  portion  of  the  mesappendix  some  distance 
from  its  base,  and  once  there  existed  a  gland  very  near  the  free  border  of  the 
mesappendix  in  contact  with  the  appendical  artery. 

Although  such  glands  have  been  reported  to  exist  in  the  mesappendix,  we 
have  not  been  able  to  demonstrate  their  presence,  save  for  one  or  two  stray 
glands  (if  very  small  size,  which,  however,  lie  so  near  the  cecum  as  to  become 
dislodged  upon  the  latter  as  soon  as  it  is  distended.  In  one  specimen  there 
were  five  glands  half-way  up  the  mesappendix,  two  of  which  received  lymph 
from  the  appendix.  As  the  mesappendix,  however,  was  identical  with  the 
ileocecal  fold,  the  posterior  surface  of  the  ileum  extraperitoneal,  ami  the 
entire  topography  of  the  ileocecal  region  presented  abnormal  conditions, 
this  group  had  to  lie  regarded  as  misplaced  ileocolic  glands.  Glands  along 
the  hilum  of  the  appendix  are,  in  our  experience,  of  very  exceptional  occurrence. 

Tixier  and  Vianney  speak  of  an  instance  where  a  gland  was  found  in  the 
thickness  of  the  appendico-ovarian  ligament  (Clado)  at  the  point  where  this 
peritoneal  fold  separates  from  the  mesappendix.  This  statement  has  met 
with  much  opposition,  and  while  we  do  not  doubt  the  reliability  of  the  observa- 
tion, the  fact  that  no  one  else  has  noted  a  gland  in  a  similar  position  shows 
that  Tixier  and  Vianney's  case  was  unique. 

THE  NERVES  OF  THE  APPENDIX. 

The  blood  and  lymph  vessels  of  the  appendix  closely  resemble  those  of  the 
neighboring  intestines,  and  the  nerves  correspond  with  them  in  this  respect. 

The  nerves  of  the  appendix  are  derived  from  the  superior  mesenteric  plexus 
of  the  sympathetic  system.     Coming  from  the  lower  anterior  portion  of  the  solar 


NERVE    .SUPPLY    OF    THE    APPENDIX.  187 

plexus,  and  the  superior  mesenteric  ganglion,  and  receiving  a  few  fibres  from  the 
right  pneumogastric  nerve,  the  superior  mesenteric  nervous  system  accompanies 
the  superior  mesenteric  vessels  throughout  the  greater  part  of  their  course. 
The  plexus  envelops  the  vascular  trunks,  subdividing  with  them  until  the 
intestinal  border  is  reached.  Some  few  of  the  nerves,  however,  leave  the  vessels 
and  run  individual  courses  in  the  mesentery.  Near  the  intestines  are  found 
frequent  anastomoses  of  the  nerves;  but  there  is  less  regularity  in  this  respect 
than  is  the  case  in  the  vascular  system. 

Having  reached  the  mesenteric  border  of  the  appendix,  the  nerves  penetrate 
the  different  coats  to  form  two  systems,  an  outer  and  an  inner.  The  outer 
plexus,  or  plexus  of  A  uerbach,  is  situated  between  the  longi- 
tudinal and  circular  muscular  coats.  It  is  composed  of  minute  sympathetic 
ganglia,  which  generally  lie  parallel  to  the  muscle-fibres.  These  ganglia  are 
connected  with  one  another  by  delicate  bundles  of  non-medullated  fibres, 
among  which  are  found  a  few  medullated.  The  cords  are  seen  to  leave  the 
ganglia  by  one  of  the  several  roots,  dividing  and  re-dividing  in  the  circular  and 
longitudinal  muscle  coats.  There  they  form  a  complicated  network,  the 
individual  branches  of  which  terminate  at  the  involuntary  muscle-cells  of  these 
layers.  This  plexus  is  also  known  as  the  plexus  m  yenteric  u  s ,  the 
name  expressing  the  function  it  is  to  perform.  There  are  a  few  larger  branches 
which  do  not  participate  in  the  formation  of  the  outer  plexus,  but  penetrate  the 
circular  muscular  layer,  and  then  enter  the  submucosa,  where  they  form  a 
second  gangliated  plexus,  the  plexus  of  Meissner,  whose  indi- 
vidual fibres  are  also  apparently  without  medullary  covering,  and  are  much 
more  delicate  than  those  of  the  intermuscular  plexus.  The  ganglia  of  this  plexus 
are  also  much  smaller  and  fewer  than  those  of  Auerbach's  plexus.  The  two 
systems  anastomose  freely  with  one  another. 

The  first  set  of  ganglia  of  Meissner's  plexus  is  situated  near  the  muscularis 
mucosa',  between  it  and  the  base  of  the  glands.  A  few  delicate  fibres  are  seen 
to  pass  from  them  into  the  muscularis  mucosa',  the  rest  passing  upward,  and 
ramifying  in  the  mucous  membrane  between  the  crypts,  the  end  fibres  being 
situated  near  or  in  the  epithelium.  According  to  Berkley,  the  nerve  fibres 
in  the  muscularis  mucosae  of  the  small  intestine  follow  the  blood  vessels  in 
twisted  bundles  of  two  or  more.  In  some  places  three  or  four  dotted  lines 
are  seen  arising  from  the  nerve  bundles,  and  forming  a  spray,  each  line  term- 
inating in  a  very  minute  knob.  In  other  places  the  dotted  lines  of  the  spray  do 
not  terminate  in  minute  single  bulbs,  but  join  together  in  a  spherical  figure, 
which  is  apparently  inclosed  in  a  transparent  capsule.  Beyond  the  muscularis 
mucosa-  the  nerve  fibres  show  a  tendency  to  ascend  toward  the  free  surface. 
Throughout  their  entire  course  they  follow,  more  or  less  closely,  the  direction 
of  the  connective  tissue  cells  between  which  they  are  located. 

There  is  a  small  number  of  ganglia  in  the  mucosa;  they  are  connected 
with  one  another,  forming  a  plexus  around  the  glands  of  Lieberkuhn,  the  end 


ISS  ANATOMY. 

twij^s  terminating  in  a  delicate  knob  or  an  elongated  swelling,  in  the  neighbor- 
hood of,  or  within  the  epithelial  lining  of  the  mucosa  and  glands.  Berkley 
says  that  each  epithelial  cell  does  nol  possess  a  nerve  twig  of  its  own,  the 
nerves  only  passing  up  to  the  epithelium  here  and  there,  showing  that  the 
nerve  force  is  not  conveyed  to  the  cell  by  direct  contact,  but  rather  through 
contiguity. 

The  anatomical  studies  upon  which  the  foregoing  remarks  arc  based  are 
still  incomplete,  as  only  fragments  of  material  have  been  available  for  investi- 
gation. Sections  of  these  fragments,  however,  appear  to  indicate  that  the 
nerve  supply  of  the  appendix,  like  its  blood  and  lymph  supply,  closely  resembles 
that  of  the  adjacent  intestine. 

BIBLIOGRAPHY. 
Auguy:  "  De  I'adenopathie  appendiculaire."    These  de  Lyon,  1901. 
Bardeleben:  "Ueber  die  I. aye  dea  Blinddarms  beim   Wenschen."     Virchow's  Arch.  f.  path. 

Anal.,  1X4N,  Bd.  2,  p.  583. 
BARNSBY:  "Those  do  Paris."  lS'.t.S. 

'■  I  (e  I'appendicite  d'origine  annexielle."     Rev.  de  gynec.,  1898,  torn.  2,  p.  419. 
Berry:  "The  anatomy  of  the  vermiform  appendix."     Anat.  Anz.,  1895,  Bd.  10,  p.  761. 

"The  caeca!  folds  and  fossa."     Edinburgh,  1S97. 
Bierhoff:  "  Beitrage  zu  den  Krankheiten  dea  wurmf5rmigen  Anhanges."     Verh.  der  phys.-med. 

Gesellsch.  in  Wurzlmrg.  1S.~>9,  Bd.  4,  p.  129. 
"  Beitrage   zu  den   Krankheiten   des   Wurmfortsatzes."     Deutsch.    Arch.   f.  klin.  Med., 

1880-81,  Bd.  27.  p.  248. 
Bryant:  "The  relations  of  the  gross  anatomy  of  the  vermiform  appendix  to  some  features  of 

the  clinical  history  of  appendicitis."      Ann.  Surg.,  1893,  vol.  17.  p.  till 
Can-vox:  "The  movements  of   the  intestine  studied  by  means  of   the   Rdntgen  rays."     Amer. 

.lour.  Physiol.,  1902.  vol.  6,  p.  251. 
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et  pathologique."    Compt.  rend.  Soc.  de  biol.,  Pari-,  1892,  9.  s.,  torn.  4,  p.  133. 
Deaver:  A  treatise  on  appendicitis,  1900. 
DorK :  "Notes  on  the  appendix  vermiformis:  anatomical  and  clinical."     Trans.  Mich.  Med.  Soc, 

Detroit,  1892,  vol.  16,  p.  114 
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med..  1895,  3.  s.,  torn.  2.  p.  1. 
FawCETT   and    BlacHFORD:  "The   length    of   the   appendix."      Proc      \nat.    Soc.    <!r.    Brit,    and 

Ireland,  1S99,  p.  20.     In  Jour.  Anat.  and  Physiol.,  1900.  vol.  34. 
Ferguson:  "Some  important  points  regarding  the  appendix  vermiformis."     Amer.  Jour.  Med. 

Sci.,  1891,  n.  s.,  vol.  101.  p.  61. 
Ferry:  "These  de  Pari-."  1900. 
Fitz:  "  Perforating  inflammation  of  the  vermiform   appendix."     Amer.   Jour.    Med.  Sci.,  1886, 

X.  S..  vol.  92,  p.  321. 
— ■ "Appendicitis:  analysis  of  seventy-two  cases."     Bost.  Nhd,  and  Surg.  Jour.,  1890,  vol. 

122.  p.  019. 
Gaston:  "The   appendix    vermiformis:  its   functions,   pathological   changes,   and   treatment." 

Jour.  Amer.  Med.  Assoc.,  1888,  vol.  10,  p.  777. 
Gegenbauer:  Vergleichende  Anatomie  der  Wirbelthiere,  1901,  Bd.  2.  p.  171. 
Gerlach:  "Zur    Anatomic    und     Entwickelungsgeschichte  des  Wurmfortsatzes."     Wissensch. 

Mitth.  d.  phys.-med.  Soc.  zu  Erlangen,  1859,  Bd.  1,  p.  7. 
"Todtliche  Peritonitis,  als  Folge  einer  Perforation  des  Wurmfortsatzes."     Zeitschr.     f. 

rat,  Med.,  1S47,  Bd.  6,  p.  12. 
Grohf.:  " Geschichtliche  Darstellung  des  Wesens  und  der  Behandlung  der  Typhlitis  und  Peri- 
typhlitis."    I.  I).,  Greifswald,  ls9fi. 


BIBLIOGRAPHY.  189 

Hartmann  :  "  Untersuchungen  an  der  Leiche  Uber  die  Perforation  des  Wurmfortsatzes."     Berlin. 

klin.  Wochenschr.,  1876,  Bd.  13,  |>.  479. 
Henle:  Handbuch  der  systematischen  Anatomie  des  Mensehen.     Braunschweig,  1871-79. 
Huntington:  Anatomy  of  the  human  peritoneum  and  abdominal  cavity,  1903. 

"Caecum  and  vermiform  appendix."     Soc,.   Lying-in   Hospital,  New  York,  Med.  Report 

(1893),  1894,  p.  121. 
Jonnesco:  Traits  d'anatomie  humaine.     (Poirier  et  Charpy),  1901,  torn.  4. 
Jonnesco  et  Juvara:  "Anatomie  des   ligaments  de   l'appendice  vermiculaire  et  de  la  fossette 

ileo-appendiculaire."     Progres  mc'd..  Paris,  1894,  2.  s.,  torn.  19,  pp.  L'73,  303,  322.  3.53. 
Kelvnack:  The  pathology  of  the  vermiform  appendix,  1893. 
Lafforqoe :  "  Recherches    anatomiques    sur    l'appendice    vermiculaire    du    caecum."     Intern. 

Monatsschr.  f.  Ai.at.  u.  Physiol.,  1893,  Bd.  10,  p.  141. 

"Des  tumeurs  primitives  de  l'appendice  vermiculaire."     These  de  Lyon,  1893. 

Lenzmann:  Die  entziindlichen  Erkrankungen  des  Darms  in   der   Regio   ileo-ccecalis   und   ihre 

Folgen,  1901. 
Little:  "Internal  strangulation;   anatomy  of  the  vermiform  appendix."     Dublin  t^uart.  Jour. 

Med.  Sci.,  1871,  vol.  52,  p.  237. 
Lockwood:  "Note  on  the  lymphatics  of  the  vermiform  appendix."     Proe.  Anat.  Soc.  fir.  Brit. 

and  Ireland,  1899,  p.  9.     In  Jour.  Anat.  and  Physiol.,  19110,  vol.  34. 
Lockwood  and  Rollestox:  "On  the  fossa'  round  the  caecum,  and  the  position  of  the  vermiform 

appendix,  with  special  reference  to  retroperitoneal  hernia."     Jour.   Anat.   and   Physiol., 

1892,  vol.  26,  p.  13(1. 
Lvsphka:  "  Leber  die  peritoneale  Umhiillung  des  Blinddarmes  und  fiber  die  Fossa  ileo-caecalis." 

Virchow's  Arch.  f.  path.  Anat.,  18(11,  Bd.  21,  p.  2S5. 
Mall:  "Ueberdie  Entwickelung  des  menschlichen  Darmes  und  seiner  Lage  beim  Erwachsenen." 

Arch.  f.  Anat.  und  Entwicklungsgesch.,  Suppl.  Band,  1897,  p.  403. 
Nothnagel:  Beitrage  zur  Physiologie  und  Pathologie  des  Darmes.     Berlin,  1884. 
Owen:  Comparative  anatomy  ami  physiology  of  vertebrates.      1866-08,  3  vols. 
Piahd:  "Des  suppurations  a  distance  dans  l'appendicite."     Arch.  gen.  de  med.,  1896,  torn.  2, 

pp.  290.  436.  oi'.O. 
Poirier:  "Situation  de  l'appendice."     Traite  d'anatomie  humaine,  torn.  4. 
Poirier  et  Cixf.o:  Traite  d'anatomie  humaine.     "  Les  lymphatiques."     (Poirier  et  Charpy), 

Paris,  1902.  torn.  2. 
Retzhs:  " Beobachtungen  fiber  Anastomosen  zwischen  V.   porta'  und  V.  cava  inferior,  etc 

Zeitscl.r.  f.  Physiol.,  1835.  Bd.  5,  p.  105. 
Ribbert:  "Beitrage  zur  normalen  und  pathologischen   Anatomie  des  Wurmfortsatzes."     Vir- 
chow's Arch.  f.  path.  Anat..  1893,  Bd.  132.  p.  66. 
Robinson:  "The  appendix  and  cecum  in  128  adult  postmortems,  with  a  new  theory  as  to  the 

cause  of  appendicitis."     New  York  Med.  Rec,  1895,  vol.  18,  p.  757. 
-   "The  appendix  in  relation  to  the  psoas  muscle,  etc."      Ann.  Sun;..  L901,  vol.  33.  p.  3s7. 
Rouget:  Jour,  de  physiol.  de  Brown-Sequard,  ls5s 

Sappev  :  "  Memoire  sur  les  veines  portes  accessories."     Jour,  de  I'anat.,  1883,  torn.  19.  p.  517. 
Tixieh  et  Viannay:  "Note  sur  les  lymphatiques  de  l'appendice  ileocaecal."     Lyon  mecl.,  1901, 

torn.  96,  p.  471. 
Toi.dt:  "  Die  Formbildung  des  menschlichen  Blinddarmes  und  der  Valvula  coli."     Sitzungsb.  d. 

k.  Akad.  d.  Wissensch.,  1894,  Bd.  103,  p  41. 
Treves:  "  The  anatomy  of  the  intestinal  canal  and  peritoneum  in  man."     Brit.  Med.  Jour..  lsv">, 

vol.  1,  p.  527. 
Tikfieu:  "Conformation  exterieure  et  vaisseaux  du  caecum."     Bull,  de  la  Soc.anat.de  Paris, 

1886,  torn.  61,  p.  652. 
Tuffier  et  Jeanne:  "Etude  anatomique  sur  l'appendice  et   la  region  ileo-caecale."     Lev.  de 

gynec,  1899.  torn.  3.  p.  235 
Vallee:  "Appendice  chez  I'enfant."     These  de  Paris,  1900. 
Waldeyer:   Hernia    retroperitonealis    nebst     Bemerkungen    zur    Anatomie    des    Peritoneums. 

Breslau,  1868. 
Zvckehkandi.  :  "  I'eher  die  Obliteration  des  Wurmfortsatzes  beim   Mensehen."     Anat.   Hefte. 

1894,  Bd.  4,  p.  99. 


CHA1TKR   VIII. 
PHYSIOLOGY. 

Has  t  li  o  ver  in  if  or  in  ;i  p  p  e  n  d  ix  a  n  y  function  ?  If  so, 
W  li  a  I  is  that  function,  anil  is  it  o  f  a  n  y  v  a  1  u  c  in  t  li  e 
animal  economy?  These  are  questions  which  have  interested  physi- 
ologists for  more  than  a  century,  and  seem  to  lie  still  as  far  from  solution  as 
ever. 

Presumption  is  all  we  have  as  yet  to  guide  us  in  answering  the  question: 
Has  the  vermiform  appendix  a  function?  Hut.  while  presumption  from  analogy 
and  from  accessory  data  may  suggest  an  affirmative  answer,  an  ultimate  deci- 
sion must  rest  upon  the  crucial  test  of  demonstration.  The  argument  from 
presumption,  briefly  stated,  is  as  follows:  We  have  in  the  appendix  a  distinct 
division  of  the  alimentary  tract,  present  in  man,  in  apes,  and  in  rodents.  Its 
position  in  relation  to  the  cecum  is  such  as  to  promote  the  escape  of  its  own 
secretions,  while  hindering  the  ingress  of  foreign  bodies  and  fecal  matter.  More- 
over, the  minute  anatomical  structure  of  the  appendix  has  characteristics 
especially  its  own,  being  peculiarly  rich  in  lymphoid  tissue,  and  so  closely 
related  to  the  tonsils  in  this  respect  that  a  near  relation  between  the  two  as 
regards  function  is  maintained  by  some  observers. 

The  most  important  evidence,  however,  in  favor  of  a  function  of  eco- 
nomic value  attached  to  the  appendix,  is  the  fact  that,  instead  of  atrophying 
before,  or  shortly  after  birth,  it  actually,  in  embryonic  life,  replaces  a  prim- 
ordial appendix  (see  " Embryology  of  the  Appendix,"  Chap.  IV),  and  then 
goes  on  to  full  development,  persisting  throughout  adult  life,  and  even  into 
extreme  old  age,  partaking  and  sharing  only  in  those  atrophic  changes  of  the 
body  at  large  which  are  the  index  of  senility. 

Against  these  facts,  on  the  other  hand,  we  have  the  numerous  experiments 
performed  in  rim  by  surgeons,  in  which  healthy,  or  relatively  healthy  appen- 
dices are  often  removed  without  deleterious  effect. 

It  is  necessary  for  us  to  accept  for  a  moment  the  argument  from  analogy 
in  favor  of  a  function  belonging  to  the  appendix,  in  order  to  reach  our  second 
hypothetical  question  :  W  h  a  t  m  a  y  that  f  u  n  c  t  i  o  n  b  e  ?  Is  it 
11  "t  hin  ";  m  ore  t  h  a  n  a  s  h  a  r  e  in  the  general  intesti- 
nal system;  or  is  it  of  a  peculiar  and  s  p e  c  i  a  1  c  h  a  r - 
a  c  t  e  r '?  Do  the  glands  of  the  appendix  merely  add  numerically  to  the  total 
number  of  microscopically  similar  glands  scattered  at  greater  intervals  through- 

190 


FUNCTION'    OF    APPENDIX.  101 

out  other  parts  of  the  intestine;  or  do  they  secrete  some,  as  yet  not  isolated 
chemical  substance,  exercising  a  special  influence  upon  digestion  at  this  point  in 
the  alimentary  tract?  The  argument  from  analogy  for  a  special  function  may 
be  briefly  stated  thus:  In  the  first  place,  the  functions  of  a  number  of  organs, 
heretofore  considered  functionless,  as  the  thyroid,  thymus,  ami  suprarenal 
glands,  have  proven  of  such  inestimable  value,  nay,  so  necessary  to  normal 
life,  that  the  scientific  physiologist  will  do  well  to  reserve  his  judgment  in  regard 
to  the  appendix,  and  occupy  an  attitude  of  expectant  observation.  Again, 
as  in  the  upper  part  of  the  digestive  tract  special  secretions  are  poured  in 
from  such  important  organs  as  the  liver  and  pancreas,  so  in  the  lower  may  we 
not  expect,  after  the  sudden  transition  from  ileum  to  colon,  to  find  some  anal- 
ogous organ  or  organs  profoundly  modifying  the  food  under  its  altered  condi- 
tions? 

In  summing  up  the  evidence,  I  can  only  repeat  that  we  await  the  final  test 
of  demonstration.  Anatomy  makes  plain  to  us  the  structural  peculiarities  of 
the  appendix,  but  leaves  us  entirely  in  doubt  as  to  the  existence  of  a  function; 
it  remains  for  the  physiologist,  or  more  properly  the  physiological  chemist,  to 
detach  the  appendix  in  some  animal  suited  for  the  purpose,  turn  it  into  the 
surface  of  the  body  and  study  its  secretions,  for  by  demonstration  alone,  as 
I  have  said,  can  the  question  of  function  be  finally  determined. 

Before  leaving  the  subject,  I  think  it  will  be  of  interest  to  give  a  brief  account 
of  the  opinions  held  by  different  distinguished  writers  of  an  earlier  date,  begin- 
ning with  the  great  Lieberkuhn. 

J.  N.  Lieberkuhn  (De  Valvula  coli  et  usit  processus  vermicularis,  I.  I).,  Lugd., 
Bat.,  1739)  says:  "The  surface  of  the  vermiform  appendix  is  full  of  glands 
secreting  a  fluid  which  mingles  with  the  feces  in  the  cecum,  and  by  diluting 
these  prevents  their  remaining  stationary  and  doing  harm.  (Hands  of  the 
same  character  are  present  in  the  cecum,  but  those  of  the  appendix  possess 
greater  strength  and  usefulness.  The  fact  that  the  appendix  contracts  at  the 
same  time  as  the  cecum,  prevents  any  foreign  body  entering  its  lumen." 

J.  Yossk  (De  intestino  cceco  ejusque  appendice  vermiformi,  I.  1'.,  (lotting..  17l!i) 
says:  "The  uses  of  the  vermiform  appendix  are  as  yet  imperfectly  understood, 
but  when  the  character  of  its  structure  is  considered,  it  will  be  seen  that  its 
uses  are  other  than  those  of  the  cecum.  The  surface  of  the  appendix  is  lull 
of  glands,  which  secrete  a  mucous,  or  rather  a  gelatinous  layer.  As  there  is 
naturally  a  tendency  for  feces  to  accumulate  and  harden  in  the  cecum,  there 
must  be  some  provision  by  which  they  are  rendered  more  fluid.  (Hands  are 
present  for  this  purpose  in  tin1  cecum,  but  they  are  not  sufficient  and  re- 
quire aid.  The  function  of  the  vermiform  appendix  is  to  provide  additional 
secretion." 

Herlin  (Jour,  de  med.  chir.  et.  phar.,  July,  1768,  p.  321)  published  some 
observations  in  regard  to  the  appendix  which  assume  that  its  function  is  mechan- 
ical. 


L92  PHYSIOLOGY. 

G.  vox  dem Buses  (De  intestino coeco ejusque processu  vermiformi,  I.  !>.,  Gott- 
ing.,  1814)  emphasizes  the  view  taken  by  Lieberkuhn  as  to  the  secretion  from 
glands  in  the  appendix  poured  into  the  cecum.  "If,"  he  says,  "the  vermi- 
form appendix  yields  a  mucous  secretion,  and  it'  this  secretion  is  the  same  as 
saliva  and  pancreatic  juice" — which  he  assumes  as  probable  "then  the  ap- 
pendix must  be  considered  as  a  second  salivary  or  pancreatic  gland,  while  the 
cecum  is  a  second  stomach." 

The  next  contribution  to  the  subject  which  I  have  found  is  thai  by  II. 
Ci  mmin,  in  the  form  of  a  letter  (Med.  Tunis  andGaz.,  L852,  vol.  2,  p,  198)  in 
which  he  suggests  that  the  appendix  is  a  remnant  of  int  ra-uterine  life,  like 
the  umbilical  ring  and  the  fossa  ovalis.  In  a  series  of  dissections  of  the  human 
fetus  at  different  stages  of  growth,  which  had  extended  over  some  years,  he 
had  always  found  the  colon  tapering  into  the  vermiform  appendix.  He  had 
also,  once,  in  a  very  young  subject,  found  the  extremity  of  the  appendix 
attached  to  the  peritoneal  surface  of  the  umbilical  ring.  Reflecting  on  these 
facts,  he  says,  and  remembering  that  the  umbilical  vesicle  and  the  white  filament 
extending  from  it  are  now  admitted  to  he  the  empty  yolk  sac  and  its  duct,  he 
has  been  led  to  the  conclusion  that  the  vermiform  appendix  is  undoubtedly 
the  anatomical  termination  of  the  vitelline  duct.  Anatomists  who  will  take 
the  trouble  to  make  the  dissections  above  alluded  to.  and  to  observe  the 
gradual  expansion  of  the  appendix  into  the  colon  as  well  as  the  length  of 
the  tapering  gut  from  the  point  at  which  the  ileum  enters,  will,  he  thinks, 
agree  with  him. 

I  have  found  nothing  further  upon  the  subject,  beyond  passing  conjectures, 
until  the  year  1888,  a  period  when  our  knowledge  of  the  appendix  was  entering 
upon  its  present  era.  H.  II.  Smith  ("  The  appendix  vermiformis,  it*  function, 
pathology,  and  treatment,"  Jour.  Amer.  Mat.  Assoc,  Inns,  vol,  10,  p.  707)  then 
writes  as  follows:  "That  the  appendix  exerts  some  influence  on  the  action  of 
the  cecum  in  digestion  is  quite  probable,  as  its  mucous  coat  differs  very  materially 
from  that  of  the  cecum  and  colon  in  the  arrangement  of  capillaries  and  mucous 
crypts,  as  shown  by  the  minute  injections  made  by  Neil!  of  Philadelphia,  in 
1851;  whilst  Gerlach  states  that  the  intervening  spaces  between  the  crypts  of 
the  appendix  are  so  prominent  as  to  make  them  look  like  small  bridges — a  marked 
anatomical  difference.  With  this  vascular  structure,  we  may  well  suppose 
that  the  secretion  of  the  appendix  is  free,  and  differs  in  some  way  from  the 
cecum.  Perhaps  it  is  the  source  of  a  lactopeptone  mixed  with  a  large  amount 
of  mucus  and  some  phosphates  or  some  carbonate  of  lime,  that  in  some  way 
mollifies  the  formation  of  feces,  and  by  its  mucous  secretion  facilitates  their 
passage  up  the  ascending  colon:  hence,  an  early  symptom  of  appendicitis  is 
constipation.  The  presence  of  an  appendix  vermiformis  in  certain  herbivorous 
animals  and  its  absence  in  the  carnivora,  would  also  seem  to  indicate  that  this 
organ  has  some  influence  on  the  digestion  of  vegetable  matter.  Tiedeman 
and  Gmelin  long  since  observed  that  the  gastric  juice  of  the  herbivora  possessed 


MOVEMENTS    OF    APPENDIX.  193 

this  power,  whilst  that  of  the  carnivora  (that  have  no  appendix)  is  not  suffi- 
ciently active  to  destroy  coarse  vegetables,  cereals,  or  hay  and  straw.'7 

We  proceed  now  to  another  question  of  physiological  interest,  namely: 
Has  the  appendix  any  p  r  o  p  e  r  in  o  v  e  m  e  n  t  s  ?  Every 
observer  who  has  examined  appendices  with  the  abdomen  open,  and  noted 
the  length  of  the  appendix  before  ami  after  removal,  must  often  have  been 
struck  by  the  fact  that  an  appendix  of  some  length  within  the  body  often  ap- 
pears much  shorter  when  removed,  and  that  an  appendix  which  is  flaccid  in 
situ  naturalis,  sometimes  becomes  firm  and  even  rigid  when  excised  and  laid 
upon  the  table.  I  have  myself  seen  an  appendix,  measuring  9.5  cm.  before 
removal,  contract  to  a  little  over  4  cm.  after  it  was  removed;  and  Van  Lennep 

IIIIIIIIIIIIIIIHIIIlllllllllllllllllllllllllllllllllllillil,j,ilii[iii,i,i.iii,ii,ii hi mm '■ » iiniiiliilillnliiiiiiiillililliilMliilil illiniBlllilllililllllillilhlllllilNllillillilllNillllHInlilill 


h 


J 


Fig.   147 


The  larger  curves  indicate  the  peristaltic  waves,  and  the  secondary  curves  the  simple  muscular  contractions. 
The  respiratory  movements  are  indicated  by  the  undulations. 

mentions  a  case  in  which  the  appendix  appeared  to  be  in  spasmodic  contraction 
and  full  of  something  that  could  not  be  emptied  by  compression,  but  as  soon 
as  it  was  removed  and  laid  upon  a  plate,  it  spontaneously  expelled  a  mass 
of  soft  feces  (Halm.  Med.  Month.,  Jan..  1895).  Xo  definite  observations 
recording  contractions  of  the  appendix  have  as  yet  been  published;  and  there- 
fore the  following  piece  of  practical  work  by  E.  Hirdox  is  of  special  value, 
giving,  as  it  does,  a  graphic  representation  of  the  contractions  of  the  appendix 
in  the  rabbit  in  response  to  stimulation  by  electricity. 

The    apparatus   used    was    similar    to    that    employed    by    Bayi.iss    and 

Starlixo    (Jour.   Plujxio}.,    1S99,   vol.    24.    p.    90")    in    their    experiments    on 

rabbits,  with  a  few  unimportant  modifications.     The  abdomen  of  a  medium 

sized  rabbit  was  opened  under  normal  salt  solution,  at  a  temperature  of  '>7.5°  C. ; 

13 


194  PHYSIOLOGY. 

a  longitudinal  incision  was  then  made  in  the  wall  of  the  cecum,  on  the  side 
opposite  to  the  attachment  of  the  mesentery,  and  a  balloon  inserted.  The 
appendix  was  next  brought  out  of  the  abdominal  cavity  and  immobilized  on 

a  small  stand,  after  which  the  levers  were  attached  to  it  by  sutures.  The 
point  where  the  balloon  was  inserted  was  then  fixed,  so  as  not  to  interfere 
with  the  motion  of  the  levers.  Small  regular  contraction 
w  a  v  e  s  foil  o  wed  the  insertion  of  the  balloon,  and  con- 
tinued to  do  s  (i .  Inflation  of  the  balloon  was  f  o  1  - 
1  o  w  e  d  1)  y  deep  r  e  ii'  u  1  a  r  peristalsis,  plainly  v  i  s  i  1>  1  e 
and     clearly    recorded    on    the    drum     (see   Fig.    147). 


CHAPTER  IX. 
NATURAL  HISTORY. 

DISEASES  TO    WHICH  THE  APPENDIX  IS  LIABLE.     ACUTE  AND  CHRONIC  APPEN- 
DICITIS.    EFFECTS  OF  AN  APPENDICITIS  UPON  THE  APPENDIX  ITSELF. 
EFFECTS  OF  AN  APPENDICITIS  UPON  THE  STRUCTURES  IN 
THE  NEIGHBORHOOD.    THE  MORE   REMOTE 
EFFECTS  OF  AN  APPENDICITIS. 

Under  the  caption  "Natural  History"  I  propose  to  give  a  brief  outline 
description  of  appendicitis  in  its  various  phases,  apart  from  symptomatology 

and  uninfluenced  by  treatment,  in  the  hope  that  by  thus  presenting  and  illus- 
trating the  different  types  of  the  disease  when  allowed  to  run  its  course  without 
interference,  I  may  be  able  to  depict  its  protean  forms  in  a  fresh  and 
vivid  manner,  and  to  demonstrate  the  various  possibilities  in  any  given  in- 
stance. I  shall,  therefore,  note  the  different  developments  of  an  appendicitis 
as  seen  by  surgeons  at  operations  in  vivo,  as  well  as  its  final  forms  as  seen  upon 
the  autopsy  table,  bestowing  equal  attention  upon  each,  but  not  discussing 
either  with  the  minuteness  of  detail  which  is  the  province  of  the  anatomist  and 
the  pathologist.  My  wish,  in  short,  is  to  treat  my  subject  as  I  should  in  a 
preliminary  talk  to  a  body  of  students,  before  entering  upon  a  more  complete 
analysis  and  a  discussion  of  the  details.  It  will  be  noted  that  some  of  the 
cases  illustrating  the  progress  of  the  disease  are  taken  from  the  older  writers, 
whose  beautiful  objective  descriptions  leave  little  to  be  desired,  while  the 
references  to  literature  are  simply  those  belonging  to  the  cases  cited,  and  make 
no  pretension  to  constitute  a  complete  bibliography. 

I  shall  consider  my  subject,  for  convenience'  sake,  under  the  following 
heads: 

1.  Diseases  to  which  the  appendix  is  liable. 

2.  Acute  and  chronic  affections  of  the  appendix. 

3.  The  effects  of  appendicitis  upon  the  appendix  itself. 

4.  The  effects  of  appendicitis  on  the  structures  in  the  neighborhood  of 
the  appendix. 

5.  The  more  remote  effects  of  an  appendicitis. 

Diseases  to  Which  the  Appendix  is  Liable. — The  vermiform  appendix 
constitutes  a  microcosm,  in  which  all  the  various  diseases  to  which  its  com- 
ponent anatomical  elements  are  liable  in  other  parts  of  the  body,  may  occur. 
From   the   presence    of    epithelial    elements    primary    adeno-carci- 

195 


196  NATURAL    HISTORY. 

n  o  in  a  is  not  infrequent.  I  have  found  upwards  of  forty  cases  so  reported 
in  the  literature,  and  there  is  no  doubl  thai  a  careful  microscopic  study  of  all 
thickened  appendices  after  removal  would  show  malignanl  disease  in  the 
organ  to  be  more  frequent  than  hitherto  suspected.  Owing  to  the  rich 
supply  of  lymph  glands  the  appendix  is  a  frequent  participant 
in  the  glandular  changes  characteristic  of  typhoid  fever.  Analysis 
cif  such  cases,  however,  shows  that  a  typhoid  affection  of  the  appendix  is,  as  a 
rule,  comparatively  unimportant,  except  as  it  may  give  rise  to  an  erroneous 

diagnosis   ill   the  early  stages   of   the  disease. 

A  few  cases  have  been  reported  of  f  i  br  o- my  o  m  a  t  a,  generally 
of  small  size,  affecting  the  muscular  and  connective  tissue  elements  of  the 
appendix.  One  such  case,  occurring  in  my  own  practice,  appeared  macro- 
scopically  to  he,  without  doubt,  an  enormous  fibroid  tumor  of  the  appendix, 
hut  a  careful  microscopic  study  of  serial  sections  showed  that  the  disease  had 
developed  in  the  contiguous  connective  tissues,  and  then  in  the  course  of  its 
growth  had  enveloped  and  buried  the  appendix  in  its  substance. 

The  peritoneal  covering  of  the  appendix  is  liable  to  he 
involved  in  a  peritonitis  arising  from  any  source  whatever.  Owing; 
to  the  contiguity  of  the  appendix  to  the  pelvic  organs  in  women,  it  may  be 
peppered  over  with  tubercles  in  tubal  tuberculosis.  Ovarian 
]>  a  p.  i  1  1  o  in  a  t  a  a  n  d  c  a  r  c  i  n  o  m  a  t  a  when  disseminated  over  the 
peritoneum  involve  the  outer  coat  of  the  appendix  as  well  as  the  adjacent 
organs. 

The  inner  mucous  surface  of  the  appendix  is  liable  to  a 
variety  of  affections  arising  from  its  direct  relationship  to  the  alimentary  tract. 
From  this  source,  various  foreign  bodies  cross  its  lumen,  where,  if  their  weight 
or  their  form  favor  their  detention,  they  may  become  nuclei  for  accretions 
<>f  earthy  salts  and  layers  of  mucus  until  the  lumen  of  the  appendix  is  choked. 
An  actinomycosis  may  arise  in  this  manner,  ami.  although  but 
few  cases  of  the  affection  have  been  reported  in  the  United  States,  [semeh  has 
published  nineteen,  and  Spickenbaum  twenty-seven;  one  case  has  occurred  in 
the  gynecological  department  of  the  Johns  Hopkins  Hospital. 

Tuberculosis  of  the  mucosa  of  the  appendix  is  often 
associated  with  ileocecal  tuberculosis;  primary  tuberculosis  of 
the  appendix,  however,  contrary  to  general  opinion,  is,  as  yet.  a  rare  disease. 
It  is  generally  believed  that  a  catarrhal  enteritis  may  produce 
changes  in  the  appendix,  but  satisfactory  demonstration  of  the  fact.  I  think, 
is  still  lacking.  J.  II.  MtJSSEB  insisted  strongly,  some  years  ago.  upon  the 
relationship  between  appendicitis  and  recurring  colitis  in  a  per- 
sonal communication,  and  G.  E.  SHOEMAKER  dwells  upon  the  same  thing  in 
an  article  entitled  :  "  The  importance  of  chronic  irritability  of  the  colon  with  mucous 
stools  as  a  symptom  of  appendicitis"  (Ann.  of  's'"r</.,  1898,  vol.  27,  p.  733). 

On  account  of  its  anatomical  position  in  the  body,  lying,  as  it  does,  exposed 


DISEASES   TO    WHICH   THE   APPENDIX    IS    LIABLE.  l'.l, 

on  the  hard  iliac  pan  and  protected  only  by  the  soft  abdominal  wall,  the  ap- 
pendix is  peculiarly  liable  to  injury  from  sudden  blows  prolonged  pressure, 
etc.;  from  this  point  of  view,  therefore,  it  may  become  a  subject  of 
medico-legal  interest.  The  anatomical  position  of  the  ap- 
pendix is  also  responsible  for  its  frequent  presence  in  right -sided 
hernias.  When  there  is  an  unusually  long  mesocecum,  permitting 
the  cecum  with  the  appendix  to  travel  over  various  parts  ,,f  the  abdomen, 
the  latter  may  be  found  in  a  hernia  on  the  left  side,  or  even  in  one  at  the 
umbilicus.  The  p  e  1  vi  c  i  n  f  1  a  m  m  a  t  o  r  y  d  i  s  e  a  s  e  s  o  f  w  o  m  e  n  . 
so  often  associated  with  pelvic  peritonitis,  also  frequently  involve  the  appendix 
when  it  lies  at  or  below  the  pelvic  brim;  it  is,  natural!}',  in  disease  of  the 
right     uterine    t  u  b  e    that  this  complication  is  usually  found. 

A  diseased  appendix  may  involve  any  of  the  organs  which  lie  within  its 
radius;  it  may  contract  adhesions  with  the  cecum,  or  with  a 
neighboring  loop  of  ileum,  into  which  it  not  infrequently  opens,  subse- 
quent  to  the  formation  of  an  abscess.  The  colon  is  often  involved  by 
the  extension  of  a  sloughing  process  advancing  by  c  ontinuit  y  of 
structure  from  the  base  of  the  appendix;  it  is  involved  by  contiguit  y 
when  a  sloughing  tip  of  the  appendix  opens  into  the  colon. 

In  fetal  life  the  appendix  is  found  lying  in  close  relation  to  the  kidney  and 
its  pelvis,  but  it  is  not  common  to  find  any  affection  of  the  urinary 
tract  traceable  to  this  source  in  the  adult.  Such  a  case,  however,  is  given 
by  F.  W.  Mott  (Trans.  Path.  Soc.  Lond.,  1889,  vol.  40.  p.  106).  A  woman, 
operated  upon  for  intestinal  obstruction,  died  a  few  days  after  operation  from 
peritonitis  due  to  ;t  perforated  appendix.  At  the  autopsy  the  appendix,  which 
measured  seven  inches  in  length,  was  found  to  fie  turned  up  behind  the  cecum 
and  mesocolon;  it  then  crossed  the  second  part  fit"  the  duodenum,  and  was 
finally  attached  to  the  front  of  the  rijrht  kidney  by  its  tip. 

There  are  a  few  cases  on  record  in  which  the  appendix  has  adhered  to  the 
bladder,  even,  in  some  instances,  with  the  formation  of  a  fistula  between 
them.  F.  Kammerer  furnishes  me  with  such  a  case,  in  which  the  appendix 
was  soldered  to  the  bladder  wall.  The  patient,  a  woman  of  forty-seven,  had 
an  abscess  which  was  opened  at  the  outer  border  of  the  rectus,  a  cupful  of 
pus  being  evacuated.  Two  days  after  the  operation  pus  was  detected  in  the 
urine,  and  six  months  later  the  abdomen  was  opened,  when  the  appendix  was 
found  f  i  r  m  1  y  a  d  h  erent  to  the  w  a  1 1  o  f  the  hi  a  d  d  e  r  ,  at  a 
point  corresponding  to  an  ulcerated  area  within.  The  appendix  was  removed, 
but  no  communication  with  the  vesical  cavity  was  found. 

Adhesions  may  also  occur  between  the  appendix  and 
the  uterus.  I  had  such  a  case  in  a  negress,  who  suffered  from  strangula- 
tion soon  after  a  confinement,  and  a  loop  of  ileum  was  found  to  have  slipped 
under  the  vermiform  appendix,  which  was  strongly  adherent  to 
the    right    side    of    the    uterus    post  e  r  i  o  r  1  y.       J.  B.  Murphy 


198  NAT!  tUX    HISTORY. 

records  an  instance  {Jour.  Amer.  Med.  Ass.,  1894,  March  .'!  i'!.  Case  98)  of  a 
woman,  twenty-four  years  of  age,  in  whom  the  cecum  was  dragged  over  toward 

the  uterus,  and  fixed  by  an  appendix  which  was  much  elongated  and  adherent 
tn  the  uterus,  thus  producing  intestinal  strangulation. 

T  li  r  o  in  b  o  s  i  s  of  t  h  e  v  e  i  n  s  go  i  n  g  to  t  h  e  a  p  p  e  n- 
d  ix  is  frequently  found  in  gangrene  of  the  organ.  In  acute  septic 
affections,  these  thrombi  extend  up  toward  the  larger  vessels,  which  may,  in 
time,  become  infected  or  convey  septic  foci  to  the  liver. 

One  of  the  most  dangerous  complications  in  an  attack  of  appendicitis  is 
the  accompanying  toxemia,  which  may  exist  with  or  without  a  defi- 
nite abscess  formation.  It  arises  from  the  excessive  formation  of  micro- 
organisms shut  up  in  the  appendix,  and  the  absorption  of  their  toxins  into  the 
circulation. 

DiErt.Ai'iiY  in  particular  ("Toxicity  de  I'appendicite,"  Presse  mid.,  1898, 
Nov.  2,  No.  92)  has  drawn  attention  to  the  toxic  character  of 
a  n  appendicitis,  arising  from  the  excessive  growth  of  pathogenic 
bacteria  under  circumstances  which  serve  to  enhance  their  virulence  in  the 
highest  degree;  the  toxins  elaborated  ami  thrown  off  in  this  slate  of  exalted 
activity  are  absorbed  by  the  vascular  system,  and  act  as  profound  poisons  to 
the  nervous  system,  producing  the  symptoms  of  collapse,  so  commonly  seen 
and  dreaded  in  grave  cases.  This  element  of  toxemia  enters  into  every 
case  to  some  extent,  and  it  becomes  one  of  the  chief  duties  of  the  surgeon  to 
detect  its  presence  and  measure  it-  severity,  in  order  to  draw  from  it  cornet 
inferences  as  to  the  condition  of  the  affected  organ.  Dieulafov's  conclusions 
are:  (1)  that  the  toxicity  of  an  appendicitis  is  a  fact  proven  by  clinical  ex- 
perience as  well  as  laboratory  experiment;  (2)  that  the  toxicity  may  he  either 
light,  or  intense  and  even  fatal;  (3)  in  its  commoner  form  it  is  manifested  by 
a  sub-icteric  skin  and  urobilinuria,  with  albuminuria;  (4)  the  icteric  color  is 
sometimes  the  sign  of  an  extremely  grave  intoxication,  affecting  the  nervous 
system  and  assuming  a  typhoid  form. 

The  organisms,  after  escaping  through  the  walls  of  the  appendix,  extend 
directly  throughout  the  peritoneum,  involving  the  contiguous  portions  of  it 
and  then  successively  invading  other  parts  of  the  peritoneal  cavity,  giving 
rise  tn  a  general  peritonitis,  or  to  discrete  abscesses  among  the  viscera.  They 
may,  however,  spread  through  the  vascular  channels,  the  lymphatics,  or  the  veins. 
giving  rise  to  secondary  deposits  which  occasion  abscesses  in  remote  parts,  such 
as  the  liver,  spleen,  pleura,  lungs,  pericardium,  parotids,  and  brain. 

Acute  and  Chronic  Affections  of  the  Appendix. — Acute  affections  of 
the  appendix  are  inflammatory  in  their  nature;  but  inflammatory  affections 
may  run  a  protracted  course,  extending  over  years,  associated  either  with  the 
walling-in  of  the  d  i  s  e  a  s  e  d  a  r  e  a  b  y  s  u  r  r  o  u  n  d  i  n  g  peri- 
toneal a  d  hes  i  O  n  S,  or  else  with  changes  in  the  interior  of  the  organ, 
such  as  c  i  c  a  trices  or  sharp  flexures,  which  give  rise  to  repeated 
attacks,  or  rather  relapses  of  the  disease. 


ACUTE   AND    CHRONIC   AFFECTIONS   OF   THK    APPENDIX.  199 

The  surrounding  structures  often  become  more  or  less  intimately  adherent 
to  the  appendix,  the  adhesions  passing  from  one  part  of  it  to  another,  or  else 
from  the  appendix  to  the  cecum,  to  the  pericecal  folds,  or  to  the  parietal  peri- 
toneum. The  appendix  itself  undergoes  various  changes  of  form  in  consequence 
of  kinks  and  bends  occasioned  in  it  by  these  adhesions  :  similar  bends  and  kinks 
may  also  result  from  a  shortened  mesappendix.     (See  fig.  148.) 

An  appendicitis  may  terminate  in  several  ways,  the  most  favorable  out- 
come being  the  entire  disappearance  of  the  disease  by 
resolution,  no  vestige  of  it  remaining.  That  the  disease  may  end  in 
this  manner  has  been  abundantly  proved  by  surgical  operations  done  after 
convalescence  from  an  attack.  Many  of  these  cases,  however,  although 
macroscopically  sound,  show  marked  pathological  changes  upon  careful 
microscopic  study.  Another  mode  of  termination  is  complete  destruction  of 
the  mucosa  causing  obliteration  of  the  canal  of  the  appendix  (appendicitis 
obliterans  of  Senn);  and  this  outcome  may  be  considered  a  favorable  one,  as 
it  obviates  all  liability  to  a  subsequent  attack.  Repeated  attacks  of  appendi- 
citis may  result  in  the  a  p  p  e  n  d  i  x  b  e  c  o  m  ing  enclosed  i  n  a  b  e  d 
of  more  or  less  extensive  adhesions,  where  it  lies  dor- 
mant as  far  as  any  further  inflammation  is  concerned;  such  appendices  are 
frequently  found  at  autopsies.  Finally,  we  may  have  a  fatal  termination 
arising  from  an  aggravated  affection  spreading  beyond  the  appendix,  involving 
the  peritoneum  or  the  vascular  system,  and  ending  in  general  sepsis,  tox- 
emia,   o  r    p  u  1  m  o  n  a  r  y    e  m  b  oli  s  m  . 

Effects  of  an  Appendicitis  upon  the  Appendix  itself. — An  appendi- 
citis may  run  its  course  in  the  mucosa  of  the  organ  as  a  simple 
catarrhal  affection.  Catarrhal  inflammation  of  the  appendix, 
however,  in  its  chronic  form,  is  not  a  common  disease,  for  when  the  infec- 
tion advances  beyond  the  mucosa  it  ceases  to  be  catarrhal,  and  becomes 
a  chronic  diffuse  appendicitis  producing  a  great  hypertrophy  of  the  walls  of 
the  appendix,  and  not  infrequently  associated  with  ulceration,  the  healing  of 
which  often  produces  cicatrices  and  stenoses,  more  or  less  complete.  When 
the  appendix  becomes  closed  by  stricture,  compression,  or 
flexure,  a  n  ace  u  m  u  1  a  t  i  o  n  of  s  e  c  r  e  t  i  o  n  s  often  re- 
sults, which,  if  the  organ  remains  uninfected,  forms  a  cystic 
appendix.  Thrombosis  or  compression  of  the  vessels  is  often  fol- 
lowed   by    necrosis     a  n  d     g  a  n  g  r  e  n  e  . 

The  concretions  or  enteroliths  so  often  found  at  opera- 
tions, are  caused  by  retained  fecal  material,  which  undergoes  a  process  of  des- 
iccation and  serves  to  excite  the  secretion  of  mucus  with  its  salts  in  excess: 
their  presence  and  their  attrition  often  serve  as  an  important  factor  in  ulcera- 
tion, provoking  an  attack  of  appendicitis  which  frequently  ends  in  perforation 
or  gangrene. 


L>()() 


\  i  I  i   R  \L    HISTORY. 


Single  kink  due  to  adhesion 
i  i  ■  ing  between  mesappi  n 
dix  an. I  neighboring  ■ 


I  ink  and  trii  lion 

due  i"  narrow  band  ol  fib 
rous  lis  >m  an 

tei  ior  to  i"  i  itei  ioi  iurfai  ■   ol 
mesentenolum 


D  kink  due  to  ad 

I  ■  ■ 
...;  to  di  -i  .1  pan 
■  ■t  appendix. 


Singlt  kinl  ■  m  tip  dm  to  ad- 
hesion ft di  ;i  'I  to  middle 

part  of  appendi 


Single  Link,  in  middh  ol  ap 
pendix,  distal  hall  flexed 
upon  proximal  half. 


Single  knit  in  UN. Ml   ■ 
b]  .1  lh<  iions  tip  Cr<  ■ 


Same,  caused  by  shortened 
mesappendix; 


Dojibk  kink  du< 
adhesions. 


I  riple    kink    due    to    short 


Same  condition  more 
pronounced. 


Spiral  turn  du<   r  i  short 
■  ■  ndix. 


■  — -^  i 


xm 


.  broad 
adhesions  to  abdominal 
tumor. 


Proximal  portion  adherent 
to  psoas  muscle .  kmk  at 
lower  angle;  disial  portion 
free  and  turned  upward  b) 
shnrt  mesappendix. 


I  >ist.i]    portion     bent    back 

■  ; itsetl  and  adherent  to 

in.  -..i[>],.  ii. II ..  and  i  ecum;  re; 
suiting  twisi  causing  mes- 
appendix i"  envelop  middle 
of  appendix. 


Appendix  adherent  to  cecum, 
lip  being  free  and  slightly 
bent  away  from  cecum. 


Fig.    148. — Various   Bends   and   Kinks   of  the  Appendix. 


EFFECTS    OF    APPENDICITIS    UPON    ADJACENT    STRUCT!   RES. 


201 


Effects  of  an  Appendicitis  upon  the  Structures  in  the  Neighborhood.— 
One  of  Nature's  most  interesting  efforts  is  her  attempt  to  limit  an  inflammation 
in  the  appendix  to  the  organ  itself,  or  its  immediate  neighborhood,  by  means 
of  an  adhesive  peritonitis  uniting  the  surrounding  tissues,  including  the  bowels. 
and  designed  to  shut  off  the  peccant  organ  from  the  abdominal  cavity.      The 


Fig.  149. — Base  of  Appendix  Covered  in  by  Dense  Sheet  of  Adhesions  Uniting  Ii.kim.  Cecum,  and  Iliac 

Fossa. 
The  exposed  distal  portion  contains  several  large  concretions,  one  as  large  as  a  date-stone.      .Mrs.  T..  op.  April 

L>4,  1901. 


shutting  off  of  the  appendix  may  be  the  result  of  repeated  attacks  of  inflam- 
mation, each  one  of  which  serves  to  agglutinate  some  additional  portion  of 
the  peritoneum.  Such  a  case  is  here  shown  (see  Fig.  140)  where  the  entire 
base  of  the  appendix  is  covered  in  by  a  sheet  of  adhesions  uniting  the  ileum, 
the  cecum,  and  the  iliac  fossa,  and  spreading  over  the  proximal  portion  of 


202  NATURAL    HISTORY. 

the  appendix.  Unfortunately,  in  such  a  ease  the  effecl  of  this  strong  web  is  to 
compress  the  base  of  the  appendix  and  imprison  the  large  fecal  concretion  in 
the  distal  portion  under  tension,  at  the  imminent  risk  of  producing  pressure 
necrosis,  and  perforation  or  gangrene.  This  circumscribed  peritonitis  with  the 
associated  distention  of  the  intestines  may  go  no  further  than  the  first  stages, 
and  with  the  disappearance  of  the  disease  ii  undergoes  complete  absorption. 
It  answers  a  mosi  useful  purpose,  however,  in  temporarily  shutting  off  the 
purulent  exudate  which  forms  in  the  neighborhood  of  the  appendix, and  thus 
preventing  it-  escape  into  the  general  peritoneal  cavity. 

It  is  not  at  all  necessary  that  the  appendix  should  he  perforated  for  an 
a  1)  sees  s    to    form    in    its    vicinity. 

A  localized  abscess  starting  in  the  neighborhood  of  the  ap- 
pendix may  remain  in  loco,  or  it  may  increase  progressively  in  ^ize  and  extend 
in  various  directions  up  or  down.  Again,  it  may  become  the  source  of  numerous 
other  abscesses  formed  successively  in  various  parts  of  the  peritoneal  cavity. 

The  appendix  may  lie  in  the  wall  on  one  side  of  the  abscess,  or  it  may  be 
found  entirely  detached  from  the  cecum  and  floating  in  the  abscess  cavity. 
The    detached    appendix    has    occasionally    been    observed    to    escape 

from  the  wound,  either  at  the  time  of  the  opening  of  the  abscess 
or  afterwards.  Such  a  case  is  that  of  Poolei  (New  York  Med.  !!<■<■..  1875,  vol. 
10.   p.   267).     The   patient,   a  girl  of  seventeen,   had   been   vaguely   ill   for  two 

weeks    when    the   svmpt  on  is    became    more   acute   and    all    abscess    formed.      Oil 

opening  this  aboul  half  a  pint  of  pus  was  evacuated,  and  the  next  day  what 
appeared  to  he  the  whole  appendix  escaped  in  a  slough- 
ing   condition.       Recovery  followed. 

A.  Worcester  of  Waltham,  Mass.  (Bost.  Med.  and  Surg.  Jour..  Aug.  4. 
1892),  reports  the  case  of  a  man.  thirty-six  years  old,  for  whom  he  opened  an 
abscess,  letting  out  some  foul  pus,  in  the  midst  of  which  the  gangrenous 
tip  of  the  appendix  was  seen,  but  as  the  rest  of  the  organ 
was  firmly  adherent  to  the  aliscess  wall,  it  was  not  deemed  prudent  to  attempt 
its  removal.      On    the   fifth   day,    however,    the  sloughing  appendix 

e  -  C  a   p  e  d     f  I   o  111     t  h  C    W  0  U  11  d  . 

I!.  L  Payne  of  Norfolk  furnishes  me  with  a  similar  case  occurring  in  a 
colored  woman,  twenty  years  old,  who,  after  repeated  attacks  of  appendicitis, 
had  a  tumor  situated  at  the  navel,  and  extending  below  it.  When  an 
incision  was  made  in  the  median  line,  just  beneath  the  umbilicus,  half  a  pint 
of  fetid  pus  escaped,  ami  the  appendix  floated  out.  The  patient 
recovered,  hut  with  a  fistula. 

DELORME  presented  to  the  Surgical  Society  of  Paris  (Bull,  et  mim.  de  In 
Sue  de  chir.,  1894,  p.  801)  an  appendix  which  had  separated  spon- 
taneously three  days  after  a  laparotomy  done  for  a  suppurative 
peritonitis.  The  specimen.  G  cm.  in  length  and  2  cm.  in  diameter,  ended  in  a 
cul  de  -iic.  and  had  lost  one  of  its  walls  hv  ulceration. 


EFFECTS    OF   APPENDICITIS    UPON    ADJACENT   STRUCTURES. 


203 


Sometimes  when  the  abscess  opens  into  the  cecum  the  detached  appendix 
e  s  c  a  p  e  s  w  i  t  h  the  pus,  travels  the  circuit  of  t  h  e  1  o  w  e  r 
alimentary  c  a  n  a  1 ,  and  is  cl  i  s  c  h  urge  d  f  r  o  m  t  h  e  r  e  c  t  u  m . 
Some  interesting  instances  are  on  record  of  this  curious  and  rare  spontaneous 
termination. 

Jackson  reports  such  a  case  (I:.r/r.  lice.  Bust.  Soc.  Mat.  Im/irov.,  1862, 
vol.  4,  p.  49)  under  the  title  "  Discharge  from  the  bowel  of  the  appendix  ceci  during 
convalescence  from  uu  acute  attack."  The  patient,  a  robust 
farmer,  twenty-tour  years  old,  had  a  severe  attack  of  ap- 
pendicitis with  abscess,  and  about  two  weeks  afterwards  he 
p  a  s  s  e  d  his  a  p  p  endix  per  rectum.  He  made  a 
good  recovery. 

W.  I..  Wallace  (Amer.  Med..  Nov.  9,  1901,  p.  745)  had  a 
similar  case  occurring  in  a  young  man,  twenty-one  years  old, 
who  was  taken  suddenly  ill  on  September  11th.  On  the  tenth 
day,  after  an  action  of  the  bowels,  the  nurse  found  an 
appendix  3.5  in.  long  in  the  stool;  it  was 
perforated  near  the  distal  extremity  and  contained  several 
concretions,  one  of  which  protruded  from  the  perforation. 
(See  Fig.  150.)  The  report  clones  with  the  remark  that  '"the 
patient  is  probably  cured  of  his  appendicitis  by  a  fortunate 
operation  of  nature." 

E.  C.  Coleman  of  Kosciusko.  Miss.,  has  furnished  me,  in 
a  personal  communication,  with  the  case  of  a  man.  forty- 
eight  years  old,  who  was  taken  ill  with  a  severe  attack  of 
appendicitis  for  which  operation  was  advised  and  refused;  at 
a  later  date   the   patient   reconsidered   his   decision,  but    his 

...  ,  ,      .  ,       .  Fig.     150. — Appendix 

condition  was  then  so  much  improved  that   operation  was  passed   by  the 

deferred.     On  the  morning  of  t lie  sixth  day,  after  taking  a  dose  '■'' " '"■ 

of  castor  oil,  he  had  a  free  alvine  evacuation  of  muco-purulent  ous,  numerous  shreds 

matter  mixed  with  some  blood,  and  at  the  same  time  felt  °>i  surface,  remains  ,.r 

outer  coats.     At  lower 

acute  pain  in  the  right  side  lasting  for  about  a  minute.     An     extremity  a  perforat- 
hour  later,  on  going  again   to  stool,  he  felt  something  pass,      '^JZ7fr'Z  w.  l.' 
which    proved    to   be   a   f  1  e  s  h  y   t  u  b  e  ,    5.5    i  n.    1  o  n  g  ,      Wallace,  of  Syracuse. 
c  1  o  s  e  d    a  t    one    en  d    a  n  d    open    at    t  h  e    o  t  h  e  r  . 
This  proved  on  examination  to  be  the  vermiform  appendix,  with  two  perfora- 
tions in  it.     The  patient  made  an  excellent   recovery. 

J.  H.  Durkee  of  Jacksonville.  Florida,  has  sent  me.  also  in  a  personal  letter. 
the  case  of  a  man  who  refused  operation  in  a  typical  attack  of  appendicitis. 
After  improving  sufficiently  to  be  up,  he  had  a  recurrence  of  the  disease,  during 
which  an  enema  of  Epsom  salts  was  given,  resulting  in  an  evacuation 
of  5  oz.  pus,  t  0  g  e  t  h  e  r  w  i  t  h  the  appendix,  which  was  about 
5.5  in.  long,  and  had  two  perforations,  one  at  the  tip,  and  another  at  a  point 
about  2  in.  from  the  base. 


_'Ul  NATT  RAL    HISTORY. 

A  11  a  li  s  cess  1'  o  r  m  L  n  g  in  the  righl  i  1  i  a  c  1  0  s  s  a  m  a  y 
open  at  any  one  of  a  number  of  points.  The  skin 
surface  directly  over  the  iliac  fossa  is  a  spot  where 
spontaneous  discharge  often  occurs,  hut  it  may  take  place  at  a  point  as 
remote  as  the  umbilicus.  An  instance  of  evacuation  in  tins  locality 
has  been  reported  by  S.  11.  Frbind  (Phila.  Med.  Jour.,  July  22,  1899),  in  which 
the  patient,  a  girl  thirteen  years  old.  was  attacked  by  excruciating  pain  in  the 
abdomen,  continuing  with  less  severity  lor  three  weeks,  at  which  time  there 
was  a  discharge  of  pus  from  the  umbilicus.  At  an  operation,  somewhat  later, 
the  opening  was  found  to  he  associated  with  an  ahscess  at  the  base  of  the  ap- 
pendix. Death  followed.  Freind  considered  that  a  patulous  vestige  of  the 
vitello-intestinal  duct  had  afforded  access  to  the  umbilicus  from  an  ahscess 
lying  posterior  to  the  appendix. 

.1.  B.  Mi 'lii'iiv  reports  a  similar  case  {.lour.  Amer.  Med.  Assoc,  1894,  March 
3-24,  Case  75)  of  a  man,  twenty-eight  years  old,  who  had  a  perforation  of 
the  appendix  with  a  circumscribed  ahscess  in  the  region  of  the  umbilicus.  Re- 
moval of  the  appendix  and  drainage  were  followed  by  recovery. 

Ahscess  connected  with  the  appendix  discharges 
most  frequently  into  the  cecum,  as  every  surgeon  of  experi- 
ence has  had  occasion  to  observe,  or  it  may  discharge  into  the  ileum. 
(See  Fig.  151.)  Discharge  into  the  reel  um  is  not  so  common.  Bayard 
Holmes  reported  such  a  case,  ami  exhibited  the  postmortem  specimen  of 
an  appendix  attached  to  the  rectum  into  which  it  had  opened  (Obst.  Gaz., 
1890,  \ol.  13,  p.  lis).  The  organ  was  obliterated  in  its  middle  portion  and 
contained  a  concretion  on  the  rectal  side  of  the  stricture.  The  right  ureter 
was  enormously  dilated,  apparently  in  consequence  of  obstruction  by  the 
adherent  appendix  lying  directly  across  it.  When  the  ahscess  opens  into  the 
bowel  spontaneously  there  is  sometimes  a  reflux  of  bowel  contents  into  the 
ahscess  cavity.  A  case  lias  even  been  put  on  record  in  which  fecal 
in  a  t  e  rial  t  r  a  veil  e  d  in  this  way  up  into  I  li  e  r  i  gh  1  pi  e  u  r  a  1 
c  a  v  i  t  y. 

In  women,  the  a  lis  cess  may  discharge  by  the  vagina, 
and  this  is  one  of  the  most  favorable  avenues  for  rapid  evacuation. 

Lastly,  the  discharge  may  take  place  by  the  bladder,  as  in  KlNG- 
don's  case,  cited  also  in  the  chapter  on  etiology,  where  a  boy  of  seven  suffered 
from  a  calculus  in  the  bladder  formed  around  a  pin,  which  hail  migrated  into 
the  bladder  from  the  vermiform  appendix.  ( i.  1!.  Fowi.EE  of  Brooklyn  furnishes 
me  with  the  case  of  a  man,  sixty-two  years  of  age,  who  had  an  attack  of  "in- 
flammation of  the  bowels,"  during  which  there  was  a  discharge  of  pus  followed 
by  fecal  matter  through  the  urethra.  A  suprapubic  operation  was  performed 
and  a  calculus  the  size  of  an  English  walnut  removed,  when  a  fistulous  opening 
between  the  bowel  and  the  bladder  was  visible  on  the  right  side,  where  the 
cecum  and  bladder  seemed   to  he  involved  in  a  mass  of  adhesions.     The  ex- 


REMOTE    EFFECTS    OF    APPENDICITIS. 


205 


istence  of  an  attachment  between  the  appendix  and  the  bladder  was  only 
presumptive  and  was  not  demonstrated. 

Krogius  (Processus  Vermiformis,  etc.,  1901,  p.  161)  mentions  the  ease  of 
a  man.  forty-eight  years  of  age.  who  had  an  enormous  abscess  associated  with 
a    perforated   appendix   pointing  in   the  gluteal  region.     This   was   ai 


Fig.  151. — Inflammatory  Residual  Mass  at  the  Tip  of  the  Appendix  Attached  to  the  Ileum  at  a  Dis- 
tance from  the  Valve.  This  Probably  Represents  the  Remains  of  an  Abscess  which  has  Emptied 
and  Drained  at  this  Point. 


first  mistaken  for  a  hernia;  hut  operation  showed  a  large  pus  cavity  over  the 
trochanter  major,  and  the  muscles  in  the  gluteal  region  wen1  full  (if  pus. 

Lastly,  an  abscess  may  point  under  the  crural  arch,  and  even  as 
low  as  the    popliteal    space. 

The  More  Remote  Effects  of  an  Appendicitis. — The  sequelje  of  an 
appendicitis,  when  the  disease  is  allowed  to  run  its  course  unhindered,  are  not 
always  limited,  unfortunately,  to  the  appendix  itself,  or  to  the  neighboring 
tissues  in  the  iliac  fossa.     Sometimes  the  sudden  perforation  of  the   appendix 


206  NATl  l;  U.    HISTORY. 

takes  the  peritoneal  cavity  by  surprise,  before  the  formation  of  any  salutary 
barriers  in  the  way  of  protective  adhesions  designed  to  wall  in  the  infection; 
in  such  a  case  as  this,  or  in  a  sudden  gangrene  of  the  appendix  due  to  vascular 
disturbances,  the  septic  material  is  distributed  throughout  the  peritoneal 
cavity,  and  a  general,  quickly  fatal  peritonitis  is  the  result.  The  precise  char- 
acter and  course  of  the  peritonitis  will  depend  on  the  character  and  virulence 
of  the  infecting  organism,  the  amount  of  infection,  and  the  rapidity  of  its  dis- 
tribution. In  fulminating  cases,  the  patient  sometimes  die-  before  the  peri- 
toneum has  the  opportunity  to  exhibit  any  well  defined  signs  of  reaction,  such 
as  vascular  congestion,  lymph,  or  suppuration. 

Quite  another  picture  is  presented  by  another  form  of  peritonitis  (pro- 
gressive fibrino-puruleni  peritonitis  of  Mikulicz)  which  advances  by  what  might 
be  called  mult  iple  foci.  The  focus  of  an  infection  is  started  in  the 
right  iliac  fossa:  another  focus  is  then  started  at  some  distance  from  this,  pos- 
sibly among  the  intestines;  a  little  later,  a  third  focus  develops  in  the  left  iliac 
fossa,  or  in  the  left  Hank:  while  possibly  still  another  focus  is  found  between 
the  liver  ami  the  diaphragm,  the  whole  process  representing  a  typical  purulent 
peritonitis. 

Even  the  pleural  cavity  is  not  immune  in  severe  cases,  when  the  infection 
travels  up  under  the  crura  of  the  diaphragm  and  causes  pie  ur  it  is  at 
first  dry.  then  exudative,  and  finally  suppurative  in  character. 
The  right  side  is  most   frequently  affected,  hut   the  left   is  not   exempt. 

A  commoner  mode  of  extension  in  empyema  of  the  right  pleura  is  by  per- 
foration of  the  diaphragm,  by  a  suprahepatic  abscess,  which  is  a  part  of  a  pro- 
gressive purulent   peritonitis. 

With  the  picture  of  a  peritonitis,  localized  or  progressive,  goes  that  of  an 
ileus  due  to  hindrance  to  the  movements  of  the  bowels,  or  to  a  kinking 
of  the  bowel  consequent  upon  adhesions,  generally  in  the  neighborhood  of  the 
ileocecal  valve.  The  symptoms  may  become  so  prominent  and  so  urgent  as 
to  mask  the  symptoms  of  the  original  disease. 

Marked  vascular  changes  are  not  infrequently  found  as>o- 
ciated  with  the  more  aggravated  forms  of  the  disease.  The  appendix  may. 
for  example,  lie  densely  adherent  to  the  iliac  artery  or  to  the  iliac 
vein,  and  from  such  a  contiguity  a  thrombosis  of  the  vein 
extending  down  the  leg  may  result.  A  case  of  adherence  to  the  iliac 
artery  was  reported  by  J.  B.  Powell  (Neio  Orleans  Mid.  and  Sura.  Jour., 
|v")l  .">.").  vol.  11.  ]).  468).  A  negro,  thirty  years  of  age.  was  taken  suddenly 
ill  with  intense  pain  in  the  bowels,  which  lasted  for  fifty  hours,  when  ho  died. 
The  autopsy  showed  a  high  degree  of  peritonitis  with  large  collections  of  pus 
between  the  intestines.  A  perforation  the  size  of  a  dime  was  found  in  the 
duodenum,  one  inch  below  the  pylorus,  with  eight  large  intestinal  worms  im- 
pacted just  below  it;  both  the  colon  and  cecum  were  distended  with  gas  and 
with  dark  colored  blood.     The  vermiform  appendix,  greatly  enlarged,  and  with 


REMOTE    EFFECTS    OF    APPENDICITIS.  207 

its  inner  coats  softened,  was  adherent  to  the  right  iliac  artery.  On  opening 
the  artery  just  below  its  commencement  a  small  round  perforation  was  found 
communicating  with  the  appendix,  through  which  clots  of  blood  regurgitated. 
There  was  a  deposit  of  lymph  around  the  aperture. 

Venous  thrombosis  is  more  apt  to  occur  in  suppurative 
cases,  such,  for  example,  as  that  reported  by  C.  A.  Freeman  i  <  'anada  Lancet, 
1871-72,  vol.  4.  p.  268).  A  young  man,  nineteen  years  old,  had  a  severe  pain 
in  the  right  iliac  fossa,  in  which  there  was  a  corresponding  area  of  induration. 
The  pain  lasted  for  two  weeks,  at  the  end  of  which  time  about  3  oz.  of  pus 
were  passed  by  the  rectum,  and  immediate  improvement  ensued.  The  tumor, 
however,  returned,  and  became  so  large  that  it  compressed  both  the  rectum 
and  the  bladder,  causing  a  constant  dribbling  of  urine  and  extreme  difficulty 
in  defecation,  the  latter  function  consuming  about  three  hours,  in  spite  of  the 
regular  use  of  laxatives.  The  abscess  was  excised  and  nearly  a  quart  of  pus 
evacuated,  but  about  ten  days  later  the  patient  experienced  a  severe  throbbing 
in  the  left  femoral  region,  followed  by  a  rapid  tumefaction  of  the  entire  limb. 
The  pain  and  swelling  continued  to  alternate  for  some  time  with  discharge  of 
pus,  when,  at  length,  a  few  small  concretions  were  discharged  and  the  patient 
recovered,  after  being  bed-ridden  four  months. 

An  interesting  case  of  the  same  kind  is  given  by  G.  A.  Browxe  (St.  Bar- 
tholomew's Hasp.  Rep.,  1880,  vol.  1C>.  p.  259)  under  the  title:  " PerityphUitis 
complicated  irith  thrombosis  of  the  femoral  rein."  A  man,  forty  years  old,  who 
had  suffered  for  years  from  flatulence  and  indigestion  was  seized  with  a  sudden 
pain  in  the  right  iliac  fossa,  which  continued  for  nearly  three  weeks,  when  he 
was  admitted  to  the  hospital  complaining  that  during  the  last  three  or  four 
days  the  pain  had  passed  down  the  front  of  the  right  thigh  and  into  the  calf. 
An  ill-defined  area  of  induration,  giving  a  dull  note  on  percussion,  was  present 
in  the  right  iliac  fossa.  The  site  of  the  femoral  vein  was  occupied  by  a  tender 
cord  filled  witli  a  thrombus,  which  extended  into  the  popliteal  space,  and  a 
superficial  vein  lying  over  the  gastrocnemius  muscle,  together  with  the  saphenous 
vein,  were  also  plugged  in  their  entire  extent.  The  patient  was  able  to  leave 
the  hospital,  improved,  in  about  six  weeks. 

Thrombosis  of  the  mesenteric  extending  into  the 
portal  v  e  i  n  is  fortunately  much  more  rare.  An  early  observation  of 
this  condition  is  that  by  E.  Atjfrecht  (fieri,  klin.  Wochensch.,  18o9.  Rd.  6, 
p.  308),  under  the  title:  "  Entzundung  des  Processus  Vermiformis;  PerityphUitis. 
Phlebitis  and  Thrombose  der  Vena  mesenterial  magna;  Pylephlebitis."  A 
young  man.  nineteen  years  old.  was  suddenly  attacked  by  abdominal  pain, 
most  marked  in  the  epigastric  region,  and  accompanied  by  chills  and  vomiting. 
His  illness  lasted  for  two  weeks,  during  which  he  suffered  from  diarrhea,  irregular 
chills,  and  pain  in  the  ileocecal  and  epigastric  regions  extending  upward  into 
the  right  shoulder.  A  slight  icterus  was  perceptible  in  the  conjunctiva.  Death 
took  place  on  the  fifteenth  day.     The  autopsy  showed   that   the  vermiform 


208  N  v  II  R  W.    HISTORY. 

appendix  was  perforated  in  three  places,  through  one  of  which  its  canal  com- 
municated with  one  of  several  abscesses  situated  between  the  ascending  colon 
and  the  abdominal  wall.  Two  more  abscesses  were  found,  one  under  the  cecum 
extending  into  the  true  pelvis,  and  another  the  size  of  a  walnut  in  the  subcecal 
fossa.  Into  the  latter  opened  the  largest  branch  of  the  superior  vein,  which 
was  the  size  of  a  crow  quill  and  perforated  at  many  places,  from  which  issued 
a  purulent  fluid.  Its  inner  wall  was  covered  with  thick,  yellowish,  caseous 
masse-.  The  same  condition  existed  uninterruptedly  through  the  superior 
mesenteric  vein  into  the  vena  porta,  and  at  the  entrance  of  the  latter  into 
the  hilum  of  the  liver  then'  was  a  purulent  mass  similar  to  that  found  in  the 
branch  of  the  superior  mesenteric  vein.  In  the  left  branch  of  the  portal  vein 
there  was  a  strong  fibrinous  exudate. 

An  abscess  of  the  kidney  came  under  my  own  observation  in 
a  woman  upon  whom  I  operated  for  J.  ('.  McCoy,  of  1'atierson,  New  Jersey. 
The  patient  had  a  large  fibroid  tumor,  and  quite  independent  of  this,  an  ap- 
pendix adherent  to  the  ureter  below  the  pelvic  brim;  in  consequence  of  this 
attachment  she  had  an  accumulation  of  pus  in  the  right  renal  pelvis,  for  which 
the  kidney  was  removed  at  a  later  date. 

A  case  of  general  s  e  r  o  -  p  u  r  ul  e n  t  peritonitis,  with  intense 
inflammation  and  swelling  of  the  appendix,  without  apparent  perforation  or 
adhesion,  and  ending  fatally,  is  given  by  A.  B.  A.NDEBSON  of  Pawnee  City, 
Nebraska  (West.  Med.  Rev.,  Nov.  L5,  1902). 

E  in  1)  o  1  i  s  in  in  the  lung  following  a  thrombosis  in  any  of  the 
vessels  communicating  with  the  vena  cava  occurs  when  (he  thrombus  becomes 
detached  and.  traversing  the  right  heart,  passes  out  into  the  lung  to  plug  one 
of  the  branches  of  the  pulmonary  artery.  When  the  embolus  is  a  small  one. 
the  patient  may  complain  only  of  a  transient  pain  in  the  side,  more  or  less 
severe  and  stitch-like  in  character;  and  doubtless  many  cases,  being  of  this 
kind,  escape  observation.  An  embolus  causing  death  in  a  case  of  an  appendi- 
citis whose  course  was  uninfluenced  by  an  operation,  is  shown  in  the  following 
case,  reported  by  M'Gregor  (Glasgow  Med.  Jour.,  Feb.,  1869,  p.  279).  The 
patient,  a  woman,  hail  noticed  a  tumor  in  the  right  iliac  fossa  for  two  months, 
which  increased  in  size  and  became  fluctuating.  The  fluid  was  about  to  be 
evacuated  when  sudden  severe  chest  symptoms  supervened,  with  dulness  in 
the  lower  lobe  of  the  right  lung  ami  absence  of  the  respiratory  murmur.  The 
physical  signs  gradually  extended  upward,  the  breath  and  sputum  became 
fetid,  and  death  took  place  twenty-six  days  after  admission  to  the  hospital. 
The  autopsy  revealed  a  perityphlitic  abscess  containing  pus  and  fluid  feces, 
with  a  perforated  appendix.  On  opening  the  chest  the  right  pulmonary  artery 
was  found  completely  plugged  with  a  firm  fibrinous  clot  extending  into  most 
of  the  ramifications  in  the  lower  lobe,  while  the  lung  was  completely  gangrenous. 

Embolism  of  the  arteries  of  the  a  p  p  e  n  d  i  x  has  been 
observed  by  J.  M.  T.  FlNNEY,  in  a  case  where  the  appendix  was  gangrenous 


REMOTE    EFFECTS    OF   APPENDICITIS.  209 

and  the  artery  to  it  completely  plugged.  After  operation  a  branch  of  the 
mesenteric  artery  became  occluded,  and  later  on  an  embolus  appeared  in  the 
artery  supplying  one  of  the  upper  extremities.  An  unusual  case  of  this  kind 
has  been  reported  by  A.  Scheibbnzuber  of  Dayton.  Ohio  (Ohio  Med.  and 
Surg.  Jour.,  1877,  N.  S.,  vol.  2,  p.  259)  under  the  title:  "Case  of  perityphlitis, 
embolism  of  tlie  left  anterior  tibial  artery,  gangrene,  amputation,  recovery."  A 
woman,  thirty-five  years  old,  robust,  fat,  and  in  good  health  was  taken  ill 
with  symptoms  of  "inflammation  of  the  bowels."  The  physician,  who  saw 
her  on  the  following  day,  found  tympany  and  pain  in  the  right  iliac  fossa,  with 
a  temperature  of  102°  F.  and  a  pulse  of  120.  There  was  general  prostration 
and  some  delirium.  A  diagnosis  of  perityphilitis  was  made,  and  eight  days 
after  the  onset  of  the  illness,  numbness  was  observed  in  both  lower  extremities; 
ten  days  later  several  patches  of  a  brown  color,  about  3  cm.  in  diameter, 
made  their  appearance  on  the  right  leg,  but  disappeared  in  a  few  days;  the 
left  leg  then  became  discolored  below  the  middle  and  was  insensible  to  the 
touch,  although  there  was  a  sensation  of  burning  heat  in  it.  Three  days  later 
still,  and  twenty-one  days  from  the  onset  of  the  attack,  a  line  of  demarcation 
was  fully  developed,  and  it  was  necessary  to  amputate  the  gangrenous  limb  in 
the  upper  third.  The  arteries  were  unusually  small,  and  in  the  anterior  tibial 
there  was  an  embolus,  below  which  the  leg  was  mummified.  The  wound  was 
almost  entirely  healed  in  three  weeks,  although  part  of  the  flaps  sloughed. 

Abscess  in  the  liver  may  be  the  result  of  a  general  infection 
arising  from  a  pyemic  process,  in  which  the  pyogenic  organisms,  in  the  form  of 
minute  emboli,  are  lodged  in  the  liver,  as  they  might  be  in  the  lungs, 
the  brain,  the  muscles,  the  kidneys,  or  other  organs.  Such  cases  are  rare,  as 
are  also  those  of  invasion  by  the  minuter  biliary  channels.  The  commoner 
mode  of  invasion  is  by  the  mesenteric  and  portal  system  of  veins  forming  a 
pylephlebitis  from  which  foci  are  distributed  through  the  liver.  A  liver 
abscess  lodged  between  the  1 i  v  e  r  and  the  diaphragm 
does  not  belong  in  the  same  category  as  those  already  referred  to,  being  in 
reality  extra-hepatic  and  sub-diaphragmatic.  Such  ab- 
scesses belong  for  the  most  part  to  the  group  of  progressive  purulent  peri- 
tonitides.  They  are  among  the  most  obscure  and  most  dreaded  of  all  the 
intra-abdominal  suppurations,  and  usually  attain  considerable  size  before  they 
are  discovered.  They  may  terminate  by  perforation  of  the  diaphragm  resulting 
in  a  suppurative  pleuritis,  or  by  perforation  of  a  bronchus. 


14 


CHAPTER  X. 

THE  VERMIFORM  APPENDIX  AT  AUTOPSY. 

ACUTE  APPENDICITIS.     CHRONIC    ADHESIVE    APPENDICITIS.     CHRONIC    OBLIT- 

ERATIVE  APPENDICITIS.     CYSTS  OF  THE  APPENDIX.     CONDITION 

OF  APPENDIX  IN  DISEASES  OF  OTHER  VISCERA. 

Introductory. — In  the  present  state  of  surgery,  the  best  opportunities  for 
studying  the  gross  pathologic  anatomy  of  the  vermiform  appendix  arc  in 
the  hands  of  the  surgeon,  for  it  is  lie  who  sees  the  organ  in  all  stages  of  disease, 

with  its  arterial  and  venous  circulation  still  active,  ami  with  its  relations  to 
surrounding  structures  undisturbed  by  manipulation.  The  minute  pathologic 
anatomy  of  the  appendix,  on  the  contrary,  is  best  investigated  by  the  patholo- 
gist. For  the  latter  purpose  the  most  suitable  material  is  that  supplied  by 
the  operating  room,  since  specimens  thus  obtained  are  in  the  most  favorable 
condition  for  the  technical  procedures  necessary  to  the  demonstration  of  the 
cellular  structures  and  the  changes  taking  place  in  them.  It  is  the  autopsy 
table,  on  the  other  hand,  which  furnishes  the  best  material  for  studying  the 
more  general  effects  produced  by  diseased  conditions  of  the  appendix  upon 
other  organs  and  structures  of  the  body.  or.  conversely,  the  effect-  of  disease  in 
other  organs  upon  the  appendix  itself,  thus  furnishing  a  comparison  with  other 
fatal  processes,  or  with  the  remote  consequences  traceable  to  lesions  of  the 
appendix.  In  the  dead-house,  only  "end  processes,"  as  a  rule,  are  met  with; 
and  the  preceding  steps  in  the  production  of  such  processes  can.  in  most  cases, 
be  only  inferred.  An  adequate  understanding  of  postmortem  appearances, 
however,  must  depend  in  every  case  upon  a  knowledge  of  both  gross  and  minute 
pathological  anatomy,  not  only  as  seen  by  the  surgeon  while  operating,  but  also 
as  observed  by  the  pathologist  while  studying  the  material  furnished  by  opera- 
tion. 

ACUTE   APPENDICITIS. 
Frequenc  y  .—The  frequency  of  acute  appendicitis  as  represented  in  the 
records  of  4028  autopsies  taken  from  three  different  sources  is  as  follows: 

The  Boston  City  Hospital.  Boston,  Mass..  Januarv  1.  1896,  to  August 
14,  1902 ' .' 1890 

The  Johns  Hopkins  Hospital,  Baltimore,  Md.,  May  28, 1889.  to  August 
13,  1902 1978 

The  Rhode  Island  Hospital.  Providence,  R.  I.,  July  1,  1900,  to  July  1 , 
1902 ' 160 

4028 
210 


FREQUENCY  OF  ACUTE  APPENDICITIS.  211 

Out  of  these  4028  autopsies,  there  were  86  cases,  or  2.10  per  cent.,  in  which 
death  was  due,  directly  or  indirectly,  to  acute  inflammatory  disease  of  the  vermi- 
form appendix.  Nothnagel,  in  44,940  autopsies  at  the  Wiener  allg 
Krankenhaus,  between  1S70  and  1896,  found  148  cases  of  appendicitis,  or  0.3 
per  cent.;  while  Eixhorx,  in  18,000  autopsies  at  Munich,  between  1N54  and 
lNN'l,  found  100.  or  0.5  per  cent.  As  the  figures  from  these  two  foreign  sources 
do  not  differ  greatly,  and  as  they  are  taken  from  larger  numbers  of  postmortem 
examinations  than  those  of  our  own  country,  they  probably  represent  the 
exact  proportion  of  deaths  from  appendicitis  more  nearly  than  ours  do.  That 
our  ratio  is  so  much  higher  may,  perhaps,  be  explained  by  the  fact  that  our 
statistics  cover  a  more  recent  period  of  time,  during  which  interest  in  the  sub- 
ject has  greatly  increased,  and  therefore  more  effort  is  made  to  obtain  autopsies 
in  such  cases  than  formerly.  However,  during  the  decade  between  1891  and 
1901  there  have  been  treated  in  the  Boston  City  Hospital  69,115  patients,  of 
which  number  8043  died,  and  of  these  deaths,  179,  or  2.22  per  cent.,  were 
due  to  appendicitis,  a  ratio  agreeing  very  closely  with  those  first  cited. 

Sex. — Out  of  our  80  cases,  57,  or  66.2  per  cent.,  were  males,  and  29,  or 
33.7  per  cent.,  were  females.  These  figures  coincide  with  the  generally  accepted 
opinion  that  appendicitis  is  more  common  in  men  than  in  women ;  it  is  contrary, 
however,  to  the  view  expressed  by  Eixhorx,  by  Ochsnek,  and  by  others. 

Age  . — Our  statistics  in  regard  to  age  are  as  follows: 

1  to  10  years 6  cases.  40  to  50  years 12  cases. 

10  "  20      "     19      "  50   "  60      "     8      " 

20  '•    .30      "     18       "  60    "    70      "     2       " 

30  "    40      "     11       "  70-80      "     1  case. 

It  will  be  seen  that  48  per  cent,  of  our  cases  occurred  in  the  second  and 
third  decades  of  life,  and  that  here  also  our  results  agree  with  the  commonly 
received  opinion  that  inflammation  of  the  appendix  is  most  common  in  young 
adults. 

Treat  m  e  n  t  . — Celiotomy  had  been  performed  in  57  out  of  our  86  ease- ; 
in  29  there  had  been  no  operation.  In  some  of  the  cases  in  which  no  operation 
had  been  performed,  the  diagnosis  was  clear,  but  the  condition  of  the  patient 
did  not  justify  operation;  in  others,  disease  in  the  appendix  was  first  discovered 
at  the  autopsy,  the  symptoms  of  it  having  been  absent,  insignificant,  or  masked 
by  pathologic  conditions  elsewhere. 

Condition  of  Appendix  . — Inasmuch  as  many  of  our  cases  had  been 
the  subject  of  operation,  the  material  was  not  always  that  best  suited  for  study- 
ins,-  the  lesions  of  the  appendix.  In  35  of  the  cases,  the  appendix  had  been 
completely  removed,  leaving  only  a  short  stump,  which  in  some  instances  was 
entirely  healed,  but  in  others  showed  no  evidence  of  healing,  the  ligature  having 
disappeared  and  an  opening  into  the  cecum  presenting,  through  which  the 
intestinal  contents  could  be  squeezed.     In  5  cases,  only  part  of  the  appendix 


I'll'  THE   VERMIFORM   APPENDIX  AT   AUTOPSY. 

had  been  removed.  In  1").  the  abscess  cavity,  or  else  the  general  peritoneum, 
had  been  drained,  without  disturbing  the  appendix,  in  29  cases  there  was 
acute  gangrenous  appendicitis  with  single  or  multiple  perforations.  In  2  of 
these,  a  gangrenous  appendix  had  entirely  sloughed  away  from  the  cecum.  In 
2.  the  remaining  proximal  portion  of  the  appendix,  part  of  which  had  been 
removed  at  operation,  showed  a  perforation.     Among  the  cases  of  perforation 

there  were  2  of  special  interest,  one  being  associated  with  typhoid  ulceration 
of  the  intestine,  the  other  with  amoebic  ulceration.  In  7  cases  there  was  an 
acute  appendicitis  without  perforation,  and  in  2  there  was  a  fibrinous  exuda- 
tion about  the  appendix,  without  any  marked  lesion  of  the  organ  itself. 

PERITONEUM. 
The  visceral  and  parietal  peritoneum  showed  an  inflammatory  exudation 
in  ol  out  of  the  Mi  cases.  Of  these  5  1  cases,  MS  had  been  operated  upon.  16 
had  not.  The  character  of  the  exudation  varied  greatly.  In  some  cases,  the 
serosa  of  the  intestines  showed  nothing  more  than  the  slightest  film  of  fibrin, 
with  a  corresponding  loss  of  the  normal  sheen  of  serous  surfaces;  in  others, 
there  was  an  abundant  exudate  of  yellowish,  friable  fibrin,  gluing  together 
adjacent  intestinal  loops,  and  forming  imperfectly  walled-off  pockets  tilled  with 
creamy  pus.  Between  these  two  extremes,  all  forms  of  exudation  were  present, 
and  the  resulting  condition  varied  in  accordance  with  the  proportions  in  which 
each  of  the  component  pails  of  the  simple  inflammatory  exudation  occurred. 
The  cases  may  lie  divided  as  follows: 

Operated  upon.  Not  Operated  upon.      Total. 

Acute  fibrinous  peritonitis 15  cases  2  cases  17  cases 

sero-fibrinous  peritonitis.  ...    7     "  1  case  8     " 

"      fibrino-purulent  peritonitis. .  13      "  9  cases  22      " 

"      purulent  peritonitis 3      "  4      "  7      " 

38     "  16      "  54      " 

In  25  cases  inspection  of  the  abdominal  cavity  at  the  time  of  the  autopsy  revealed 
no  signs  of  any  tendency  toward  limitation  of  the  inflammatory  process  to  the 
immediate  vicinity  of  the  appendix,  nor  was  there  anything  pointing  to  a  pre- 
vious abscess  in  the  region  of  it.  In  29  cases  it  was  evident  that  there  had,  at 
first,  been  a  localizing  process  resulting  in  an  abscess,  either  completely  or 
incompletely  walled  off,  and  that  subsequently  a  leakage  had  taken  place  from 
this  abscess,  causing  infection  of  the  peritoneal  cavity  and,  finally,  a  general 

peritonitis. 

Operated  upon.     Not  Operated  rrox.       Total. 

General  peritonitis  without  peri-appen- 

dical  abscess 16  cases  9  cases  25  cases 

I  leneral  peritonitis  with  peri-appendical 

abscess 22     "  7      "  29     " 

38     "  16      "  54      " 


PERI-APPEXDICAL   AND   PELVIC    ABSCESS.  213 

Peri=appendical  Abscess. — A  walled-off  cavity  filled  with  pus,  or 
drained  and  lined  by  fibrin  or  granulation  tissue,  was  found  in  connection  with 
the  appendix  in  47  out  of  the  86  cases.  Of  these  47  cases,  leakage  with  general 
peritonitis  had  occurred  in  29. 

Operated  upon.     Not  Operated  upon.       Total. 

Peri-appendical  abscess  with   general 

peritonitis 22  cases  7  cases  29  cases 

Peri-appendical  abscess  without  gen- 
eral peritonitis 13      "  5     "  18      " 

35      "  12     "  47      " 

The  situation  of  the  abscess,  in  a  large  proportion  of  cases,  was,  naturally,  the 
right  iliac  fossa.  The  pelvis  was  next  in  frequency.  Abscesses  occurred  also 
in  other  situations,  but  there  was  no  great  variety  of  them.  The  more  common 
situations  are  tabulated  here: 

In  right  iliac  fossa  below  cecum 27  cases 

In  right  iliac  fossa  behind  cecum 6      " 

In  right  lumbar  reigon 3      " 

In  pelvis 10      " 

In  mid-line  just  above  pelvic  brim 1  case 

47  cases. 

The  size  of  the  abscess  varied  from  a  cavity  2.5  cm.  in  diameter  to  one  filling 
the  entire  pelvic  space  and  containing  a  large  amount  of  pus.  The  walls  of 
the  abscess  cavity  were  formed  by  the  cohesion  of  neighboring  viscera  and 
portions  of  the  parietes.  The  viscera  commonly  involved  were  the  cecum, 
loops  of  small  intestine,  the  bladder,  the  rectum,  and  in  the  female,  the  uterus 
and  the  broad  ligament. 

Pelvic  Abscess. — The  condition  of  the  pelvis  deserves  some  attention 
owing  to  the  comparative  frequency  of  abscess  formation  in  this  locality,  and 
the  difficulty  in  securing  adecpiate  drainage  for  pus  collected  in  this  dependent 
part  of  the  abdominal  cavity.  In  our  86  cases  of  acute  appendicitis,  25  showed 
involvement  of  the  pelvis.  In  some  of  these  there  was  a  definitely  walled-off 
abscess,  completely  separated  from  the  general  peritoneal  cavity;  in  some, 
again,  the  separation  was  only  partial;  in  others,  the  pelvis  showed  merely  a 
collection  of  pus  in  no  way  separated  from  the  general  cavity;  while  in  others 
still,  the  participation  of  the  pelvis  was  manifested  only  by  a  more  marked 
deposit  of  fibrin.  In  many  of  the  cases  which  had  been  operated  upon,  gauze 
drains  had  been  introduced  between  the  wound  and  the  pelvis;  and  in  these, 
there  was  evidence  of  a  partial  or  complete  drainage  of  a  former  abscess.  Of 
these  25  cases,  as  has  already  been  seen,  10  were  peri-appendical  abscesses. 
In  the  remaining  15  the  appendix  did  not  enter  into  the  pelvis  and  in  many  of 
them  it  was  remote  from  the  pelvic  brim.     In  this  latter  group  of  cases,  the 


2]  1  THE    VERMIFORM   APPENDIX    AT   AUTOPSY. 

surgeon,  having  found  the  appendix  and  treated  it,  is  likely  to  overlook  the 
pelvic  condition  and  leave  an  abscess  cavity  undrained,  to  remain  a  source  of 
septic  absorption,  or,  by  leakage,  to  produce  a  general  peritonitis. 

Subphrenic  Abscess. — Since  the  classical  publication  of  v.  Leyden  in 
1880,  much  interest  has  attached  to  subphrenic  abscesses  in  their  various  forms. 
They  may  occur  in  either  subphrenic  space;  if  iii  the  right,  they  will  lie  bounded 
above  by  the  diaphragm,  below  by  the  liver,  to  the  left  by  the  suspensory  liga- 
ment of  the  liver  {Ligamentum  suspensorium  hepatis),  ami  by  the  abdominal 
parietes;  if  they  occupy  the  left  subphrenic  space,  to  these  boundaries  will  he 
added  below  the  stomach  and  spleen,  this  space  not  being  so  sharply  circum- 
scribed as  the  right.  Between  the  two.  the  suspensory  ligamenl  of  the  liver 
forms  a  barrier  which,  as  a  rule,  prevents  the  abscess  from  being  bilateral. 
The  ligament  may.  however,  be  eroded  anil  the  process  extend  from  one  side 
to  the  other.  In  exceptional  instances  the  extension  has  advanced  from  one 
side  to  the  other  behind  the  liver,  in  front  of  the  vertebral  column,  or,  again, 
abscesses  have  originated  simultaneously  on  both  sides,  so  that  the  entire  sub- 
phrenic space  is  occupied  by  purulent  material,  but  separated  by  the  intact 
suspensory  ligament. 

The  origin  of  these  abscesses  varies  greatly:  those  on  the  right  side  are 
more  commonly  due  to  a  direct  extension  of  an  inflammatory  process,  proceed- 
ing from  the  liver,  from  appendical  and  peri-appendical  lesions,  from  perforation 
of  the  duodenum,  ami,  more  rarely,  from  perforation  of  the  stomach;  on  the  left 
side,  perforation  of  the  stomach  is  the  most  frequent  cause.  Of  the  total  number 
of  cases,  the  cause,  according  to  NOTHNAGEL,  lies  oftenest.  perhaps,  in  a  round 
ulcer  of  the  stomach.  Other  etiological  factors  are  inflammatory  conditions 
of  the  kidneys,  gall  bladder  and  ducts.  echinOCOCCUS  of  the  liver,  and  the  ex- 
tension of  an  inflammatory  process  from  the  thoracic  wall  or  contents.  These 
abscesses  may  contain  only  purulent  material  (abscessus  subphrenicus)  or  puru- 
lent material  mixed  with  gas  {pyopneumothorax  subphrenicus  of  v.  Leyden). 
The  gas  comes  either  from  perforation  of  some  air-containing  viscus,  or  is  pro- 
duced in  situ  by  the  bacterial  flora  present,  either  the  bacillus  aero- 
genes  capsulatus  (Welch)  or  some  one  of  the  bacillus  coli 
c  o  m  m  u  n  i  s  group.  This  last  form  may  occur  as  a  complication  of  appen- 
dicitis, as  in  a  case  reported  by  Umber.  These  two  forms  are  often  separated, 
since  the  latter  presents  a  distinct  clinical  picture,  although  etiologically  and 
anatomically  they  are  the  same. 

Subphrenic  abscess  is  not  frequent.  Maydl  collected  170  cases  from  litera- 
ture, ami  Lang  173,  to  which  he  added  3  new  ones.  Yet.  if  we  consider  the 
frequency  with  which  subphrenic  abscess  follows  appendicitis,  it  would  seem 
to  be  a  more  common  affection  than  these  figures  indicate.  Among  110  autop- 
sies occurring  during  the  past  two  years  at  the  Boston  City  Hospital.  G  cases  of 
subphrenic  abscess,  exclusive  of  those  following  appendicitis,  have  been  found. 
Of  these,  3  were  right,  and  3  were  left  sided.    Those  on  the  right  side  followed 


SUBPHRENIC   ABSCESS.  215 

a  perforated  gastric  ulcer,  acute  suppurative  cholecystitis,  and  typhoid  fever 
respectively;  those  on  the  left  side  were  the  result  of  pyothorax,  cholelithiasis 
with  suppurative  cholangitis,  but  no  liver  abscess,  and  acute  hemorrhagic  pan- 
creatitis.    In  2  of  the  6  cases,  the  diaphragm  showed  gross  perforation. 

Of  Matdl's  179  cases  of  subphrenic  abscess,  23  were  secondary  to  appen- 
dicitis. Lang,  out  of  176  cases  of  right-sided  subphrenic  abscess,  found  20  due 
to  appendicitis.  Sachs  in  1895  reported  41  cases  in  which  he  included  25  of 
Mavdl's,  although  2  of  these  should  have  been  excluded,  because  their  primary 
source  lay  in  a  perforation  of  the  cecum  by  a  foreign  body.  Weber,  in  1900, 
reported  9  cases  of  subphrenic  abscess  out  of  600  cases  of  appendicitis  operated 
upon  by  Sonnenburg;  of  these  600  cases,  350  had  a  peri-appendical  abscess, 
so  that  the  9  cases  of  subphrenic  abscess  form  2.5  per  cent,  of  the  abscess  cases. 
In  a  later  paper,  Weber  has  added  5  cases  from  Soxxexburg's  clinic.  Els- 
berg  reports  2  cases  of  subphrenic  abscess  (upon  which  he  operated)  out  of  91 
cases  of  appendicitis,  and  he  has  collected  71  cases  complicating  appendicitis, 
making,  with  his  own  2,  a  total  of  73  cases.  Moreover,  he  excluded  anumberof 
cases,  because  the  reports  were  meagre  or  incomplete.  Since  the  date  of  his 
article,  single  cases  of  subphrenic  abscess  have  been  reported  by  Robixsox 
(1889),  Cayley  (1900),  Blake  (1901),  Gastox  (1901),  Dale  (1901),  and  others. 

As  Weber  found  2^V  per  cent,  of  subphrenic  abscesses  out  of  350  cases  operated 
on,  and  Eesberi;  2  cases  in  91  consecutive  appendicitis  operations,  and  as  we 
ourselves  have  found  an  inflammatory  condition  of  the  subphrenic  region  fre- 
quently present  at  autopsies,  we  think  it  a  justifiable  conclusion  that  sub- 
phrenic abscess  is  not  a  very  unusual  complication  of  appendicitis;  the  cases  of 
it,  however,  have  not,  as  a  rule,  been  reported. 

In  our  series  of  86  cases  of  appendicitis,  the  subphrenic  region  was  affected 
in  7,  or  8.13  per  cent.,  although  not  each  one  of  these  cases  was  a  subphrenic 
abscess  in  the  strict  sense  of  the  word.  As  these  cases  present  a  number  of 
differences,  as  well  as  several  points  of  interest,  the  autopsy  protocols  will  be 
given  in  some  detail. 

I.— B.  C.  H.     9S.217.     J.  H.,  male,  age  twenty-six. 

A  n  a  t  o  in  i  c  a  1  1 )  i  a  g  n  o  s  i  s  . — Scar  of  former  appendix  operation  :  acute 
fibrinous  general  peritonitis;  chronic  adhesive  localized  peritonitis;  retrocecal,  peri- 
splenic, and  subphrenic  abscesses;  right  pyothorax;  acute  sero-fibrinous  pleuritis, 
leftside;  complete  atelectasis,  right  lung;  partial  atelectasis,  left  lung;  acute  bron- 
chitis; acute  purulent  mediastinitis ;  volvulus  of  small  intestine;  thrombosis  of 
vessels  of  liver.     Cloudy  swelling  of  kidneys. 

In  the  right  groin  is  a  scar  4^  cm.  in  length,  running  parallel  to  Poupart's  liga- 
ment, dark  blue  in  color  and  slightly  depressed  below  the  surrounding  skin  (opera- 
tion six  months  ago  lor  appendicitis). 

Peritoneal  Cavity. — On  opening  the  abdomen  the  coils  of  the  small 
intestine  an'  greatly  distended,  hyperemic,  and  covered  with  thin  Hakes  of  fibrin. 
The  coils  of  intestine  are  united  hv  easily  broken,  fibrinous  adhesions.     In  the  region 


216  THE   VERMIFORM   APPENDIX   AT  AUTOPSY. 

of  the  appendix  and  cecum  arc  numerous  linn,  fibrous  adhesions,  in  the  meshes  of 
which  the  appendix,  with  an  obliterated  lumen,  is  found.  The  diameter  of  the 
appendix  is  much  decreased.  Posterior  to  the  cecum  is  found  an  abscess  cavity 
containing  a  considerable  amount  of  thick,  creamy  pus.     The  spleen  is  walled 

off  from  the  general  cavity  by  firm  adhesions,  and  lies  in  a  mass  (if  the  same  thick 
creamy  pus.  This  pus  is  very  adherent  to  the  capsule  of  the  spleen  and  is  only 
scraped  off  with  some  difficulty.  The  right  lobe  of  the  liver  is  bound  to  the  dia- 
phragm by  recent  adhesions.  On  separating  these,  there  is  found  to  be  a  layer  of 
the  same  thick  creamy  pus  lying  between  the  liver  and  the  diaphragm  on  the  right 
side.  Immediately  over  the  left  lobe  of  the  liver  there  are  fresh  adhesions,  but  no 
pus.  On  examining  the  small  intestine,  120  cm  above  the  ileocecal  valve,  a  com- 
plete twist  of  the  bowel  is  found.  All  of  the  small  intestine  below  this  point 
as  well  as  the  large  intestine  is  collapsed. 

P  1  e  u  r  a  1  C  a  v  i  t  i  e  s  . — The  right  pleural  cavity  contains  1800  CC.  of  thick 
creamy  jius.  The  pleura  is  thickened,  and  covered  with  soft,  yellowish,  fibrin  Hakes. 
The  left  pleural  cavity  contains  800  CC.  of  a  dark  reddish  fluid  in  which  are  numerous 
large  flakes  of  fibrin.  The  fluid  here  is  not  purulent.  The  parietal  pleura  is  also 
adherent,  and  shows  the  same  appearance  as  the  right;  in  addition  there  are  numer- 
ous small  hemorrhages  beneath  it. 

Lung. — Right  lung  is  flattened  against  the  spinal  column,  and  completely 
atelectatic.  Left  lung  atelectatic  along  the  back  of  the  upper  ami  middle  lobes, 
hut  the  inner  and  anterior  portions  of  the  lung  still  contain  air.  Bronchial  glands 
enlarged  and  pigmented. 

1)  i  a  p  h  r  a  g  m  . — Both  sides  covered  with  an  exudate  of  fibrin.  No  perfora- 
tion. 

Spleen. — Weight  140  gms.,  capsule  thickened  and  covered  with  thick  pus; 
on  section,  of  a  uniform  bright  red  color;  Malpighian  bodies  not  prominent;  pulp 
not  increased. 

L  i  v  e  r  .—Weight  1720  gms.  (see  p.  228). 

Cultures  . — Heart's  bl 1 — S  treptococcus   pyogenes.     Spleen — 

Streptococcus  pyogenes,  micrococcus  lanceolatus,  and 
bacillus  c  o  1  i  communis.  Kidney — Sterile.  Right  pleural  cavity — 
Streptococcus  pyogenes,  micrococcus  lanceolatus.  Sub- 
phrenic abscess — S  treptococcus     pyogenes  in  almost  pure  culture. 

Micms  c  o  p  i  c  E  x  a  m  in  at  i  on  . — bung — Well  marked  organization  is 
taking  place  along  the  pleural  surface.  The  granulation  tissue  consists  chiefly  of 
thin-walled,  widely  dilated  capillaries.  Lung  tissue  more  or  less  compressed. 
Blood-vessels  injected.     Spleen — Organization   is  taking  place  along  the  surface. 

I>1 l-vessels  not  so  numerous  as  on  pleural  surface.     Infiltration  with  lymphoid 

and  plasma  cells  is  greater. 

II.— 15.  C.  H.     00.11.").     E.  A.,  female,  age  thirty-time. 

A  natomical  Diagnosis  . — Peri-appendical,  pelvic,  and  subphrenic  ab- 
scesses;   chronic   localized   adhesive   peritonitis;    acute   fibrino-purulent   pleuritis, 

right  side;  atelectasis,  right  lung:   operation  wounds. 

In  the  right  iliac  region  there  is  a  healed  scar  7  cm.  long,  and  external  to  this 


CASES   OF   SUBPHRENIC   ABSCESS.  217 

scar  there  is  an  incision  7  cm.  long,  entering  the  peritonea]  cavity  at  the  right  side  of 
the  cecum,  through  which  a  gauze  drain  passes  to  the  region  of  the  appendix. 

Peritoneal  Cavil  y  . — The  surface  of  the  general  peritoneum  is  smooth, 
glistening,  and  dry.  The  region  of  the  appendix  and  the  end  of  the  cecum  are 
surrounded  by  slight  adhesions  and  bloody  diffluent  material.  The  point  of  origin 
of  the  appendix  is  difficult  to  find,  and  its  stump  is  apparently  perfectly  healed. 
The  pelvis  is  walled  off  by  rather  strong  adhesions,  involving  the  omentum,  the 
small  intestine,  the  sigmoid  flexure,  and  the  apex  of  the  bladder.  On  separating 
these  adhesions  the  pelvis  is  found  rilled  with  dirty  pus-like  material.  No  direct 
connection  between  this  and  the  condition  about  the  appendix  can  be  made  out. 
Between  the  diaphragm  and  the  right  lobe  of  the  liver  there  is  a  small  collection  of 
dirty  pus-like  material,  which  communicates  with  the  exterior  by  means  of  a  wound 
passing  through  the  base  of  the  right  pleural  cavity. 

Pleural  Cavities. — The  left  pleural  cavity  is  normal,  and  also  the 
anterior  part  of  the  right  pleural  cavity.  The  lateral  and  posterior  parts  of  the 
right  cavity,  from  base  to  apex,  and  the  right  half  of  the  base  are  walled  off  by 
rather  firm,  fibrinous  adhesions,  and  filled  with  700  cc.  of  fibrino-purulent  exudate. 
The  pleural  walls  are  here  covered  by  thick  layers  of  fibrin.  This  cavity  communi- 
cates with  the  exterior  by  the  incision  before  mentioned. 

Lung  s. — The  left  lung  is  pink,  downy,  and  normal  in  appearance.  The  right 
lung  is  normal  in  the  posterior  and  apical  portions,  but  in  the  other  parts  it  is  covered 
with  fibrinous  exudate.  Its  tissue  is  soft  and  spleen-like  in  character,  and  a  bit 
of  it  sinks  in  water. 

Spleen  . — Weight  100  grams.  Purplish  in  color  and  somewhat  redticed  in 
consistency. 

Cultures. — Heart,  spleen,  liver,  kidneys,  lungs,  pleurae,  and  peritoneum — 
Bacillus   c  o  1  i   communis. 

Microscopic  Examination . — Liver — Shows  marked  central  cirrhosis 
with  increase  of  tissue  around  central  vein,  obliteration  of  capillaries  and  diffuse 
hemorrhage.  Lung — Completely  collapsed  and  atelectatic.  Its  pleural  surface 
shows  organization  of  a  fibrinous  exudation. 

III.— B.  C.  H.     01.110.     H.  P...  male,  age  thirty-five. 

Anatomical  Diagnosis. — Operation  wounds;  removal  of  appendix; 
acute  fibrinous  general  peritonitis;  mesenteric  and  portal  pyophlebitis ;  multiple 
abscesses  of  liver;  acute  splenic  tumor;  parenchymatous  nephritis. 

The  skin  is  generally  slightly  icteric,  and  the  conjunctivae  are  distinctly  yellow. 
In  the  median  line  is  an  incision  through  the  abdominal  wall,  8  cm.  in  length,  begin- 
ning 1  cm.  above  the  umbilicus  and  extending  to  within  3  cm.  of  the  xyphoid  car- 
tilage. In  the  right  lower  quadrant  of  the  abdomen  is  an  "appendix"  incision 
4  cm.  in  length.     Both  wounds  are  closed  by  sutures. 

Peritoneal  C  a  v  i  t  y. — The  peritoneal  surface  is  lustreless.  All  the  coils 
of  bowel  are  slightly  adherent  by  easily  broken  fibrinous  shreds.  In  the  cavity  of 
the  pelvis  is  a  small  amount  of  sero-sanguineous fluid.  In  the  region  of  the  appendix 
the  stump  only  is  found,  and  on  pressure  nothing  escapes  from  the  cecum.  Bounded 
by  the  spleen,  the  stomach,  the  left  side  of  the  diaphragm,  the  liver,  and  the  posterior 


218  TIIK   VERMIFORM    APPENDIX    \T   AUTOPSY. 

wall  of  the  peritoneal  cavity  is  an  abscess,  containing  offensive,  yellowish,  semi-fluid, 
purulenl  material.  Its  wall  is  everywhere  covered  by  a  fibrinous  membrane,  aboul 
1  cm.  in  thickness,  which  is  readily  detached.  Smears  from  pus  in  the  subphrenic 
abscess  show  flattened  streptococci.  Mesenteric  lymph  nodes,  all  somewhat  en- 
larged. 

M  e  s  e  n  t  e  r  i  c   a  n  il     ]>  o  rial   v  e  i  n    (see  p.  2M4). 

Cultures. — Heart's  him  id  Streptococcus  p_y  o  g  e  n  e  s,  b  a  c  i  1  - 
1  u  s  c  o  1  i  c  ii  in  m  u  ii  is.  Liver  —  St  r  e  p  1  o  c  o  c  c  u  s  p  y  o  g  e  n  e  s, 
bacillus  coli  cum  munis.  Spleen  —  Bacillus  proteus.  Kid- 
ney -  B  a  c  il  1  u  s  coli  c  o  m  m  u  n  is.  Peritoneum  (beneath  omentum) — sterile. 
Blood  from  vessel  near  portal  vein — S  treptococcus  pyogenes,  bacil- 
lus   colic  o  m  m  n  n  i  s  .* 

IV.— B.  C.  IT.     02.91.     G.  C,  male,  age  thirty-three. 

A  n  a  t  o  m  i  c  a  1  1 )  i  a  g  n  o  s  i  s. — <  (peration  wound  ;  appendix  removed ;  peri- 
typhlitis; volvulus  of  small  intestine ;  acute  sero-fil irinous  peritonitis;  subphrenic 
abscesses;  chronic  tuberculosis  of  lung  and  spleen;  tuberculous  ulcerations  of 
ileum;   chronic  interstitial  nephritis. 

Midway  between  umbilicus  and  anterior  superior  iliac  spine,  there  is  an  operation 
wound  parallel  with  the  rectus  muscle. 

1'  rrii  o  n  e  a  1  Cavil  y. — About  200  >■<•.  of  greenish-yellow  fluid  in  the 
sub-diaphragmatic  regions  of  both  sides,  smear-  from  which  show  a  variety  of  bacteria 
including  streptococcus  pyogenes.  The  coils  of  intestine  are  markedly 
meteoric.  The  exudate  in  the  lower  ahdoiiH'ii  is  less  fluid  and  more  fibrinous  than 
higher  up,  and  glues  together  the  coils  of  the  intestine.  The  sub-diaphragmatic 
surface  of  the  liver  shows  fresh  fibrin  in  smooth  flakes  which  can  lie  easily  peeled 
away.  The  right  lower  angle  of  the  liver  shows  greenish  fibrin,  and  also  an  exu- 
date which  appears  to  have  affected  the  liver  substance  itself. 

2  to  3  cm.  internal  to  the  appendix  incision,  a  portion  of  the  wall  of  the  cecum 
has  become  firmly  adherent  to  the  abdominal  wall,  and  presents,  on  separation,  a 
fibrous  ragged  surface  with  considerable  old  hemorrhage.  Appendix  is  absent  (at 
operation  a  gangrenous  appendix  already  sloughed  off  had  been  removed);  its 
stump  is  buried  in  a  blackish  mass  of  tissue  lining  the  inside  of  the  deep  pocket 
beneath  the  incision. 

Pleural  Cavil  ies. — Left,  normal.  Right,  completely  obliterated  by  old 
adhesions. 

( '•  a  s  t  r  o  -  i  n  t  e  s  t  i  n  a  1  Tract. — Stomach  normal :  duodenum  irregularly 
and  brilliantly  injected  over  the  tops  of  some  of  the  /'»</■/.  The  small  intestines  are 
remarkably  dilated,  the  circumference  in  places  being  13  cm.  At  a  point  300  cm. 
below  the  pylorus  is  a  knot  lying  internal  to  the  appendix  region.  This  is  so  arranged 
that  the  lower  Bowel  for  a  distance  of  1">  cm.  curls  forward,  upward,  and  outward, 
to  lie  caught  in  the  mesentery  behind  and  constricted  to  the  measure  of  a  linger. 
The  intestine,  so  looped,  is  markedly  injected ,  lmt  nowhere  hemorrhagic.  Three 
Peyer's  patches  in  the  region  of  the  cecum  show  old  ulcers  from  ^  to  1  cm.  in  diam- 

*  Cultures  made   from  heart    blood   and  blood  vessels   by  aspirating  with  a.  syringe  and 
adding  blood  to  media. 


CASKS    OF    SUBPHRENIC    ABSCESS.  219 

ctor,  oval  in  shape,  with  long  axes  at  right  angles  to  those  of  the  affected  pal  eh.    The 
borders  of  the  ulcers  are  slightly  raised,  and  injected  with  occasional  spots  of  hem- 
orrhage; the  craters  are  pale  and  fairly  smooth. 
Live  r. — Weight    1500  gins.     Normal. 

V.— R.  I.  H.     00.1.     .1.  C,  male,  age  fifty. 

Anatomical  I)  i  a  g  n  o  s  i  s. —  Operation  wound  ;  acute  ulcerative  appen- 
dicitis; peri-appendical  abscess;  extension  of  abscess  into  retroperitoneal  and  peri- 
nephric tissues;  perforation  of  ascending  colon;  acute  localized  peritonitis;  edema 
of  lungs. 

There  is  an  operation  wound  in  the  right  groin  beginning  2  cm.  to  the  inner 
side  of  the  anterior  superior  spine  of  the  right  iliac  bone  and  extending  upward  and 
outward  parallel  to  the  crest  of  the  ilium  for  a  distance  of  6  cm.  The  abdomen  is 
distended. 

Peritoneal  C  a  v  i  t  y. — The  peritonuem  is  smooth,  except  about  the  seat 
of  operation.  The  mesenteric  lymph  nodes  are  not  enlarged;  there  is  no  fluid  in 
peritoneal  cavity.  The  intestines  are  distended  by  gas,  with  slight  fibrinous  adhe- 
sions to  the  abdominal  wall  around  the  operation  wound.  These  adhesions  are  easily 
separated,  exposing  two  openings  ;  one  just  external,  the  other  internal  to  the 
cecum,  both  extending  into  the  retroperitoneal  tissues.  From  them  a  yellowish, 
semi-fluid,  fecal  material  escapes. 

A  p  p  e  n  d  i  x. — The  base  only  is  visible,  arising  from  the  posterior  wall  of  the 
lower  end  of  the  cecum  and  extending  inward  along  the  brim  of  the  pelvis,  with  tin- 
tip  slightly  curled  upon  itself.  It  is  firmly  bound  down  by  old  fibrous  adhesions  and 
measures  12  cm.  in  length.  The  proximal  6  cm.  appears  normal,  while  the  distal 
portion  is  riddled  with  perforations,  from  some  of  which  escapes  a  yellowish  fecal 
fluid.  The  abscess  about  these  perforations  communicates  with  the  retroperitoneal 
space  into  which  the  openings  about  the  cecum  lead.  In  the  posterior  wall  of  the 
cecum  is  an  almost  spherical  opening,  about  H  cm.  in  diameter,  leading  into  the 
retroperitoneal  tissues  as  well.  The  retroperitoneal  tissue  here  is  softened  and 
diffusely  infiltrated  with  a  brownish-gray,  puriform  material;  this  extends  upward 
as  a  grayish-yellow  exudate,  in  places  muco-purulent,  and  elsewhere  in  masses  of  a 
tough,  apparently  fibrinous  material.  It  invades  the  right  psoas  muscle,  extends 
along  the  vena  cava  inferior,  posterior  to  the  duodenum  as  it  crosses  the  spinal 
column,  and  infiltrates  everywhere  the  perinephritic  tissues  of  the  right  side,  even 
extending  between  the  diaphragm  and  the  liver. 

Liver. — Weight  1360  gms.  It  presents  no  abnormalities  in  shape.  It  is 
brownish-red,  rather  lax  in  consistence,  while  on  section  the  surface  is  dry  and  the 
markings  indistinct.     From  the  blood-vessels,  bubbles  of  gas  escape. 

Kidneys. — The  left  weighs  130  gms.,  i^  rather  dark  red  in  color,  with  con- 
sistence apparently  unchanged;  its  capsule  strips  easily,  leaving  a  smooth  surface. 
On  section,  the  cortex  is  rather  pale,  not  diminished  in  thickness.  The  pyramids 
are  well  marked  from  the  cortex.  The  right  kidney  is  about  the  same  size  as  the 
left.  With  the  perinephric  tissues  it  weighs  270  gms.  The  cortex  is  very  pale, 
looking  as  though  it  had  been  boiled,  all  the  markings  appearing  very  indistinct. 
A  teased  specimen  shows  a  small  amount  of  fat  in  the  cells  of  the  tubules. 


220  THE    VERMIFORM    APPENDIX    AT   AUTOPSY, 

Righl  Adrenal.—  [s  SO  much  involved  in  the  porinophritic  abscess  as  to 
be  indistinguishable. 

Bacteriology.  Streptococci  arc  present  in  culture  from  heart's 
blood,  peritoneum,  and  perinephric  tissue.  A  chromogenic  bacillus 
which  turns  the  media  bright  red  in  forty-eighl  hours  is  found  in  cultures  from 
lung,  spleen,  liver,  and  peritoneum.  Hits  of  tissue  from  liver,  lung,  heart,  and 
kidney  placed  in  thermostat  overnight,  ail  show  large  numbers  of  bacilli  with 
the  morphological  and  staining  properties  of  the  bacillus  aerogenes 
capsulatus. 

VI.— J.  II.  II.     1581.— Female,  age  thirty-two. 

A  n  a  t  o  in  ical  D  i  a  g  nosi  s. — Operation  wounds;  acute  gangrenous  ap- 
pendicitis; peri-appendical  pelvic  abscess;  subphrenic  abscess;  acute  fibrino-puru- 
lent  general  peritonitis;  acute  splenic  tumor;  cloudy  swelling  of  myocardium, 
kidneys,  and  liver;  edema  and  congestion  of  lung-;  healed  tubercular  foci  in  lungs; 
acute  sero-fibrinous  pleuritis,  both  sides,  chronic  adhesive  pleuritis,  both  sides. 

Under  the  right  edge  of  the  rectus  abdominis  muscle  is  a  recent  surgical  incision, 
17  cm.  in  length,  with  the  middle  third  containing  a  gauze  drain,  while  the  upper 
and  lower  thirds  are  closed  and  healing  ptr  primam.  In  the  right  Hank  postero- 
laterally  is  a  recent  surgical  incision  '■'>  cm.  in  length,  containing  drains. 

P  e  r  i  t  o  n  e  a  1  C  a  v  i  t  y . — Upon  opening  the  peritoneal  cavity,  the  intestines 
are  found  adherent  to  the  anterior  abdominal  wall  by  firm,  fibrinous  adhesions, 
which  are  present  everywhere,  except  in  the  region  of  the  splenic  flexure  of  the 
colon.  Between  the  loops  are  numerous  pockets  of  pus.  Upon  untwisting  the 
coils  of  intestine,  it  is  found  that  the  appendix  is  gangrenous  and  has  sloughed  off 
at  its  attachment  to  the  cecum.  The  detached  portion  dips  over  the  brim  of  the 
pelvis, and  is  contained  in  a  large  abscess  containing  about  half  a  pint  of  thick, grayish- 
yellow,  foul-smelling  pus.  The  abscess  cavity  occupies  Douglas'  cul-de-sac.  The 
stump  of  the  appendix  is  shut  off  by  one  of  the  gauze  drains.  The  other  gauze  drain 
lies  against  the  colon  on  its  lateral  side.  A  rubber  drain  leads  into  an  abscess  cavity 
between  the  liver,  the  hepatic  flexure,  and  the  lateral  abdominal  wall.  The  liver 
has  between  its  right  lobe  and  the  chest  wall  an  extensive  abscess,  which  extends 
also  over  the  lower  surface  of  the  diaphragm  almost  to  the  median  line. 

G  astro-intestinal  Tract . — The  stomach  contains  about  a  pint  of 
dark  fluid ;  the  duodenum  is  clear,  but  at  the  upper  end  of  the  jejunum  are  several 
ecchymoses  over  the  mucous  membrane;  otherwise  the  small  intestine  is  clear.  1 'oyer's 
patches  over  the  lower  portion  of  the  ileum  are  somewhat  swollen  and  red.  There 
is  an  ecchymosis  on  the  free  border  of  the  ileocecal  valve.  The  large  intestine  is 
considerably  injected,  with  numerous  ecchymoses  in  the  mucous  membrane.  The 
solitary  follicles  of  the  large  intestine  are  swollen.  In  the  cecum  is  a  long  piece  of 
a  flat  worm;  the  remainder  of  the  worm  extends  through  the  whole  length  of  the 
small  intestine,  and  doubles  back  upon  itself. 

Liver. — Weight  1800  gins.;  dimensions  25  X  23  X  8  cm.  The  surface  is 
covered  with  a  layer  of  fibrin  adjacent  to  the  abscess,  but  is  otherwise  normal.  On 
section,  the  liver  is  somewhat    mottled,  the  general  color  being  rather  a  brownish- 


CASES    OF   SUBPHRENIC    ABSCESS.  221 

gray,  and  in  areas  £  cm.  in  diameter,  of  a  pale,  opaque,  yellowish  color.     The  con- 
nective tissue  is  increased  in  amount,  the  lobules  plain. 

ML— J.  H.  H.     I860.— Male,  age  eleven. 

A  n  a  t  o  m  i  c  a  1  I)  i  a  g  n  o  s  i  s . — Removal  of  appendix ;  acute  general  fibrin- 
ous peritonitis;  extensive  multiple  abscess  formation  in  the  peritoneum;  subphrenic 
abscess;  acute  diphtheritic  colitis;  acute  pleuritis,  left  side. 

Peritoneal  Cavity. — Upon  opening  the  peritoneal  cavity,  delicate 
fibrinous  adhesions  are  found  everywhere  between  the  abdominal  organs  and  the 
anterior  abdominal  wall.  There  is  a  small  abscess  in  the  subcutaneous  tissue  com- 
municating with  the  granulating  surface  of  the  wound  by  a  channel  at  the  lower 
end.  The  abdominal  organs  are  much  bound  together,  and  an  attempt  to  separate 
them  ruptures  the  intestines.  There  are  delicate  adhesions  everywhere  between 
the  intestinal  coils.  Just  under  the  diaphragm  on  the  left  side,  is  a  large  abscess 
cavity,  located  outside  of  the  stomach  and  partially  walled  off  by  the  liver,  which 
contains  greenish-yellow  pus.  This  cavity  is  lined  by  a  rough  hypereniic  granula- 
tion tissue,  thrown  up  into  folds,  which  arc  almost  like  the  valvulae  of  the  intestines. 
Pressure  on  the  abscess  causes  the  pus  to  exude  from  another  cavity  in  the  ileocecal 
region,  and  a  probe  can  be  passed  .30  cm.  along  the  right  abdominal  wall  without 
meeting  resistance.  The  channel  can  be  traced  with  the  scissors  from  the  subphrenic 
abscess  into  the  ileocecal  region,  where  it  turns  toward  the  centre,  giving  rise  to 
numerous  channels  passing  down  between  the  intestinal  coils.  Another  abscess 
filled  with  fluid  is  found  just  behind  the  transverse  colon  ;  this  cavity  is  continued 
around  over  the  aorta,  where  it  overlies  the  ascending  colon.  The  ileocecal  valve 
is  practically  in  its  normal  position.  In  the  walls  of  the  abscess  there  are  black 
silk  sutures  at  the  point  where  the  cecum  lies  against  the  abscess  cavity,  probably  at 
the  seat  of  the  appendix.  On  the  left  side,  midway  down  the  course  of  the  abscess 
cavity,  there  is  a  fistulous  communication  with  the  ileum.  The  kidney  lies  quite 
free  behind  the  abscess.  The  transverse  colon  at  the  splenic  flexure  crosses  the 
abscess  and  lies  behind  it ;  the  abscess  is  not  therefore  retroperitoneal.  The  channel 
follows  almost  exactly  the  course  of  the  colon  down  to  the  region  of  the  bladder, 
where  it  crosses  over  through  the  sinus  opening  on  the  abdominal  surface.  The 
abscess  cavity  on  the  right  side  extends  up  to  the  region  of  the  liver,  where  it  ends 
blindly.  The  pancreas  is  free  and  apparently  normal.  The  main  coils  are  inex- 
tricably embedded  together,  and  there  are  numerous  adhesions  and  abscesses  be- 
tween these  coils.  An  attempt  to  separate  them  results  in  tearing  the  intestines. 
The  abscesses  very  often  lie  between  the  adhesions  of  the  mesentery  and  omental 
folds;  they  are  more  dense  about  the  region  of  the  ileocecal  valve. 

Lungs. — The  left  lung  is  somewhat  collapsed  in  the  lower  lobe,  where  it  is 
firmly  adherent  to  the  diaphragm. 

Spleen. — The  spleen  is  bound  down  by  adhesions  and  its  capsule  is  much 
thickened  by  granulation  tissue.  It  forms  the  lateral  wall  of  the  large  abscess 
described.  The  splenic  substance  is  firm  and  slightly  grayish  in  color.  The  ele- 
ments of  the  spleen  are  well  defined. 

Gastro-intestinal  Tract . — The  stomach  is  normal,  the  folds  of  the 


222  THE   VERMIFORM    APPENDIX    AT   AUTOPSY. 

colon  hemorrhagic,  the  more  prominent   ones  having  on  their  crests  a  fibrinous 
exudate. 

L  i  v  e  r .—Measures  23  X  16  X  7.5  cm.  It  is  quite  densely  adherent  to  the 
diaphragm.  On  section  it  is  homogeneous  and  reddish-brown  in  appearance;  its 
lobules  are  extremely  indistinct;  the  gall-bladder  is  apparently  normal. 

Analysis  of  Cases  of  Subphrenic  Abscess.  -In  6  of  these  7  cases  the 
affection  was  unilateral,  4  of  them  being  on  the  right  side,  and  2  on  the  left; 
in  1  case  only  was  it  bilateral.  Subphrenic  abscess  following  appendicitis  is 
more  frequent  on  the  right  side,  indeed  the  cases  of  Lang,  Weber,  Elsberg, 
and  Umber  were  all  on  the  right  side.  Strange  to  say,  Elsberg  does  not  seem 
to  consider  the  left  subphrenic  region  at  all  in  treating  the  subject,  and  in  his 
table  of  collected  cases  the  site  of  the  disease  is  not  mentioned.  If  we  consider 
the  manner  in  which  these  abscesses  originate  when  secondary  to  disease  of 
the  appendix,  it  is  plain  that  the  right-sided  form  is  necessarily  more  frequent, 
although  they  can  easily  occur  upon  the  left  side.  The  localization  is  always 
influenced  by  the  position  of  the  appendix. 

Subphrenic  abscess  secondary  to  appendicitis  may  occur  in  one  of  four  ways: 

1.  As  a  localized  abscess,  forming  part   of  a  general  purulent   peritonitis. 

2.  By  extension  of  the  diseased  process  from  the  appendix  to  the  subphrenic 
region  by  an  intraperitoneal  route. 

3.  By  extension  of  the  diseased  process  through  an  extraperitoneal  route. 
either  by  way  of  the  lymphatics,  or  by  infiltration  through  the  retroperitoneal 
tissue. 

4.  By  way  of  the  blood  current,  as  part  of  a  general  embolic  septic  process, 
or  as  a  sequence  of  liver  abscesses — which  are  of  embolic  origin — by  way  of  the 
portal  vein. 

When  the  abscess  originates  in  either  the  first  or  the  fourth  ways,  it  can 
appear  with  equal  readiness  on  either  side;  when  it  arises  in  the  second  manner, 
either  side  may  be  affected,  but  the  right  side  is  much  more  frequently  so,  since 
the  ascending  colon  forms  a  natural  drain  or  gutter  in  its  direction;  when  the 
abscess  originates  in  the  third  manner,  the  left  side  can  only  rarely  be  involved, 
and  if  it  is  so,  a  misplaced  appendix  will  generally  be  found  associated  with  it. 

The  greater  number  of  subphrenic  abscesses  originate  by  extension  (methods 
2  and  3).  Whether  the  route  in  any  given  case  will  be  intra-  or  extraperitoneal 
depends  on  the  situation  of  the  appendix  and  the  peri-appendical  process.  If 
the  latter  is  retrocecal,  and  so  retroperitoneal,  the  chances  are  that  the  process 
will  take  an  extraperitoneal  route,  and  reach  the  subphrenic  region  by  way  of 
the  loose  areolar  tissue  in  the  lumbar  region.  It  is  claimed  thai  when  the  ab- 
scess is  retrocecal  there  is  greater  liability  to  the  formation  of  a  subphrenic 
abscess. 

When  the  abscess  reaches  the  subphrenic  region  by  the  extraperitoneal  route 
it  may  remain  outside  the  peritoneum,  or  it  may  become  intraperitoneal.     In 


Fir,.    1">:?.— Senile  Atrophy  of  Cecum  in   Man   Eightt-six  Years  Old. 
The  shrinkage  -if  the  colic  anil  cecal  pouches  has  loft,  in  situ,  the  lateral  subserous  vessels,  some  of  which  by 
anastomosis  with  t ho  lumbar  veins  enter  the  systemic  circulation  (vena  cava).     These  are  the  vessels  first  men- 
tioned by  Retzius.     See  also  Fig.  139. 


224 


PORTAL    VEIN.  225 

the  former  case  it  is  usually  small,  since  the  peritoneum  covering  the  diaphragm 
is  intimately  adherent  to  the  muscle  substance  (Hofmann,  A.  .Schmidt,  cited 
by  Elsberg).  For  the  same  reason  it  is  likely  to  penetrate  early  into  the 
space  between  the  diaphragm  and  the  liver.  In  Elsberg'-  cases  27  per  cent, 
were  extraperitoneal,  48  per  cent,  intraperitoneal,  and  25  per  cent,  of  doubtful 
anatomic  location. 

The  different  methods  in  which  subphrenic  abscesses  may  originate  are  well 
illustrated  in  the  cases  just  quoted,  indeed  all  four  methods  of  origin  are  shown 
among  the  7  cases.  In  case  I,  there  was  a  retrocecal  and  right-sided  subphrenic 
abscess,  the  latter  arising,  apparently,  through  the  extraperitoneal  route, 
although  the  case  was  complicated  by  volvulus  of  the  small  intestine,  general 
fibrinous  peritonitis,  fibrinous  adhesions  between  the  left  lobe  of  the  liver  and 
the  diaphragm,  and  thrombosis  of  some  of  the  veins  in  the  liver.  Case  II  also 
illustrates  an  extraperitoneal  route  to  the  right  subphrenic  space,  but  in  this 
instance  the  general  peritoneal  cavity  was  clear.  In  case  III  pylephlebitis  and 
multiple  liver  abscesses  were  present,  and  the  subphrenic  abscess  was  on  the 
left.  Case  IV  shows  bilateral  subphrenic  collections  of  pus  forming  part  of  a 
general  peritonitis.  In  case  A",  an  infiltrating  purulent  process  could  be  clearly 
traced  extending  upward  from  the  region  of  the  appendix  along  the  retro- 
peritoneal tissues  of  the  right  lumbar  region,  and  finally  making  its  appearance 
between  the  diaphragm  and  the  liver.  In  case  VI  the  course  of  the  process 
is  not  very  clearly  traceable,  although,  as  a  general  peritonitis  and  several  pus 
pockets  were  present,  it  may  have  arisen  as  a  part  of  the  general  peritonitis. 
Case  VII  shows  an  intraperitoneal  route  of  extension  from  the  appendix  to 
the  left  subphrenic  region. 

In  4  of  the  7  cases,  the  process  had  extended  from  the  subphrenic  region 
into  the  pleural  cavity,  though  in  none  of  them  was  the  diaphragm  perforated. 
In  case  II  it  had  been  incised  by  the  surgeon  for  drainage.  The  pleural  affection 
in  these  cases  will  be  considered  later  in  connection  with  the  subject  of  pleurisy 
complicating  disease  of  the  appendix  and  its  relationship  to  perihepatitis, 
which  Lapeyre  regards  as  an  early  stage  of  subphrenic  abscess. 

PORTAL  VEIN  AND  ITS  BRANCHES. 
The  vermiform  appendix,  like  other  parts  of  the  intestinal  tract,  is  supplied 
with  a  rich  network  of  venules  which  ramify  in  its  various  coats.  These  unite 
into  larger  and  larger  radicles,  finally  forming  the  appendical  vein  which 
empties  into  the  ileocecal  branch  of  the  superior  mesenteric,  and  in  this  way 
becomes  part  of  the  portal  circulation.  The  region  of  the  appendix  is  also 
supplied,  but  less  richly,  by  branches  from  the  systemic  venous  system,  which 
anastomose  with  those  from  the  portal  venous  system  by  means  of  the  veins  of 
Retzius.  (See  Eig.  152.)  Both  of  these  systems  are  of  importance  in  connec- 
tion with  appendicitis,  the  former  in  relation  to  pyophlebitis  of  the  superior 
15 


226  THE    VERMIFORM    APPENDIX    VI     U   rOPSY. 

mesenteric  and  the  portal  veins,  the  latter  in  explaining  the  etiology  of  pul- 
monary embolism  in  some  appendix  cases. 

In  1890  autopsies  at  the  Boston  City  Hospital,  thrombosis  of  the  portal  vein 
occurred  in  15  cases,  of  which  in  were  associated  with  appendicitis.  These 
will  lie  discussed  in  the  next  division  in  connection  with  pylephlebitis  and  liver 
abscess. 

LIVER. 

Associated  with  the  acute  infectious  process  in.  or  originating  from,  the 
appendix,  the  liver  may  show  acute  parenchymatous  degeneration  (the  focal 
or  central  necrose-  described  by  Mallory),  acute  interstitial  hepatitis,  acute 
perihepatitis,  and  abscesses.  Acute  parenchymatous  degeneration  was  present 
in  many  of  the  cases.  In  cases  studied  microscopically,  necroses  of  both  types 
were  occasionally  seen.  Acute  interstitial  hepatitis  was  found  in  3  of  the  Boston 
City  Hospital  cases.  Acute  perihepatitis  occurred  in  cases  of  general  peritonitis, 
subphrenic  abscess,  or  liver  abscess,  and  is  considered  in  connection  with  these. 
Liver  abscess  is  described  in  connection  with  pylephlebitis. 

Pylephlebitis  and  Liver  Abscess. — Of  the  different  complications  of 
appendicitis  few  are  of  greater  interest  than  pylephlebitis  and  liver  abscess 
These  conditions  were  recognized  early  in  the  history  of  the  disease,  but  for  a 
long  time  they  were  considered  very  rare:  later  on,  however,  the  number  of 
such  cases  reported  greatly  increased,  until  they  are  now  no  longer  regarded 
as  unusual  complications  or  sequela?  of  appendicitis.  Berthelin,  reviewing 
the  early  literature  of  the  subject,  cites  as  the  first  case  that  of  Hillairet  in 
1849,  in  which,  at  the  autopsy,  an  abscess  was  found  occupying  the  right  iliac 
fossa  and  the  pelvis,  which  contained  the  appendix,  in  part  ulcerated  and  de- 
stroyed, while  the  divisions  of  the  left  branch  of  the  portal  vein  were  filled 
with  pus.  Buhl,  in  ls.">4,  reported  a  case  in  which  there  were  multiple  liver 
abscesses.  Loison,  however,  attributes  to  Waller  an  earlier  case  than  either 
of  these,  in  is  Hi. 

Berthelin  in  1895  collected  28  cases.  Loison  in  1900  published  one  case,  and 
says  that  in  French  literature  a  certain  number  of  isolated  cases  of  liver  abscess 
associated  with  appendicitis  have  been  reported,  but  that  there  are  no  statistics 
showing  the  relative  frequency  of  the  association  in  France.  He  regarded 
such  cases  as  quite  rare.  Barensprpng  out  of  7326  autopsies  in  Berlin  between 
lvV.t  and  ls73  found  Ids  cases  of  liver  abscess,  and  of  these  8  had  followed 
affections  of  the  cecum  and  the  appendix.  Dudley,  in  1892,  out  of  28,034 
patients  at  the  Zurich  clinic,  between  1870  and  1891,  found  12  cases  of  liver 
abscess,  2  of  which  had  followed  disease  of  the  appendix.  Kobler,  in  10(11. 
reported  70  cases  of  liver  abscess  out  of  17,204  autopsies  at  Vienna,  occurring 
between  1881  and  1890,  including  '■)  which  followed  "typhlitis"'  or  "peri- 
typhlitis "  and  in  of  liver  abscess,  none  of  which  were  the  result  of  appendicitis, 
out  of  1307  autopsies  at  Sarajevo  between  1894  and  1000.     Jackson,  in  1S99, 


LIVER   ABSCESS.  227 

reported  17  cases  of  liver  abscess,  10  of  which  he  regarded  as  the  result  of  appen- 
dicitis. Among  28  cases  of  liver  abscess  reported  by  Hart  in  1900,  there  were 
17  of  pylephlebitis,  the  origin  of  which  is  referred  in  3  cases  to  the  appendix. 
Einhorn,  in  1891,  found  100  cases  of  peritonitis  following  appendicitis  out  of 
Is. 000  autopsies  at  .Munich  between  1854  and  1889;  in  these  100  there  were  6 
cases  of  pylephlebitis  and  liver  abscess.  Langheld,  in  1890,  found  4  cases  of 
pylephlebitis  and  2  of  liver  abscess  out  of  112  autopsies.  Fitz,  in  1886,  gave 
11  cases  of  pylephlebitis  as  occurring  in  257  cases  of  perforating  appendicitis. 
Bokchardt  in  1897  found  5  cases  of  pylephlebitis  in  378  cases  of  appendicitis; 
and  Matterstock  in  1880  gave  11  of  pylephlebitis  and  metastatic  liver  abscess 
in  146  cases.  Munro,  in  1901,  reported  4  cases  of  portal  infection  following 
appendicitis,  the  diagnosis  of  which  was  confirmed  at  operation  or  at  autopsy. 
To  these,  in  a  second  paper,  1902,  lie  added  6  cases.  5  of  which  are  included  in 
our  series  of  autopsies.  Single  cases  have  been  reported  by  Krackowitzer 
(1871),  Colquhoun  (1887),  Jorand  (1894),  Sheen  (1896),  Rare  (1897),  Dieu- 
lafot  (1898),  Trowbridge  (1900),  Dale  (1901),  Stooke  (1901),  and  others 
cited  elsewhere  in  this  chapter,  so  that  the  total  number  of  recorded  cases  is 
now  a  large  one. 

According  to  Soxxexburg,  pylephlebitis  and  liver  abscess  as  complications 
of  appendicitis,  do  not  occur  as  often  as  subphrenic  abscess,  for  he  observed 
only  .")  cases  of  the  former  as  compared  with  15  of  the  latter  in  the  large  number 
of  cases  upon  which  he  operated  for  appendicitis.  In  our  series  of  86  cases  of 
appendicitis  occurring  in  402S  autopsies,  however,  we  found  10  cases  of  pyle- 
phlebitis and  liver  abscess  (11.62  per  cent.)  as  compared  with  7  cases  of  sub- 
phrenic abscess  (8.13  per  cent.).  Strange  to  say,  9  of  these  10  cases  occurred 
among  the  1S90  Boston  City  Hospital  autopsies,  while  only  1  was  found  in  the 
1978  Johns  Hopkins  Hospital  autopsies,  and  none  at  all  in  the  160  belonging  to 
the  Rhode  Island  Hospital,  though  the  numbers  of  cases  of  appendicitis  in  each 
group  were  respectively  49,  32,  and  5.  No  satisfactory  explanation  for  this  fact 
has  been  found. 

The  ten  cases  from  the  Boston  City  Hospital  were  as  follows: 

I.— B.  C.  II.     97.286.     G.  K.,  male,  age  thirty. 

A  n  at  n  m  i  r  a  1  Diagnosi  s. — Chronic  appendicitis;  abscesses  of  mesen- 
teric lymph  nodes:  suppurative  pylephlebitis;  multiple  abscesses  of  liver:  acute 
splenic  tumor;   chronic  fibrous  pleuritis. 

Peritoneal  C  a  v  i  t  y . — About  200  cc.  of  brownish,  cloudy  fluid  presenl  : 
old  adhesions  of  great  omentum  to  right  iliac  wall:  appendix  and  cecum  bound 
down  by  old  adhesions.  Mesenteric  lymph  nodes  enlarged  and  softened:  mesentery 
generally  thickened. 

Pleural  ('  a  v  i  t  i  e  s. — Left  pleura  adherent  to  lung  along  the  spinal  border. 
Right  pleura  adherent  to  extreme  end  of  lower  lobe. 

Pericardial   Cavity . — Normal. 

Lungs. — Increased  in  density,  slightly  congested. 


228  THE  VERMIFORM    APPENDIX    AT   AUTOPSY. 

S  p  le  e  n  .—  Weight  475  gms.  Large,  rather  soft,  capsule  smooth.  Malpighian 
corpuscles  no1  visible ;  pulp  much  increased. 

I,  i  v  c  r . — Weight  2565  gms.  <  >n  the  anterior  surface  run  be  seen  many  small 
whitish  patches,  especially  on  the  left  lobe.  On  the  under  surface  of  the  left  lobe 
are  areas  of  multiple  abscesses,  one  about  (i  ■  5  cm.  in  diameter  near  the  upper  left 
border,  and  another  near  the  inferior  border  of  the  same  lobe.  ( >n  the  under  surface 
of  the  right  lobe  are  many  whitish  spots.  Section  shows  abscess  formation,  espe- 
cially in  the  left  lobe,  and  dilation  of  the  portal  vein,  which  is  filled  in  part  with 
rather  firm,  yellowish  masses,  and  in  part  with  pus.  On  opening  up  the  portal  vein 
and  its  branches,  they  are  found  occluded  by  yellowish,  adherent  thrombi,  and  thick 
yellow  pus. 

A  p  p  e  n  d  i  x  .-  Is  bound  down  by  old  adhesions ;  the  canal  is  patent  and  tilled 
with  pus:  the  mucous  membrane  is  roughened  and  ragged,  showing  evidence  of  old 
inflammation. 

Cu  1  t  ii  res  . — Heart,  liver,  spleen,  liver  abscess,  mesenteric  lymph  node,  and 
appendix  show  a  variety  of  bacilli,  principally  bacillus  coli  com- 
m  u  n  i  s  . 

Microscopic  Examination. — Section  of  the  portal  vein  shows  a 
thrombus  principally  composed  of  fibrin  and  leucocytes,  irregular  in  shape  and 
at  one  point  almost  surrounding  an  area  containing  numbers  of  red  corpuscles,  in 
which  are  great  numbers  of  bacilli.  Section  of  kidney  shows  acute  degenerative 
lesions.  In  the  spleen  the  follicles  are  small,  and  the  pulp  increased:  there  is  no 
necrosis:  the  formation  of  epithelioid  cells  is  marked:  there  are  some  plasma  cells. 
The  liver  shows  changes  everywhere.  The  vessels  are  universally  dilated  and  in 
the  portal  spaces  there  are  large  accumulations  of  cells,  chiefly  plasma.  Around 
some  of  the  larger  spaces  there  is  marked  formation  of  connective  tissue.  In  the 
capillaries  then'  are  large  numbers  of  cells,  definite  polynuclear  leucocytes,  plasma 
cells  and  the  large  transitional  forms.  There  are  several  abscesses  in  the  section. 
In  the  neighborhood  of  the  abscesses  the  liver  cells  are  atrophic.  The  more  definite 
abscesses  shown  mass  of  fibrin  and  bacteria  in  the  centre,  and  around  this,  areas 
of  polynuclear  leucocytes  with  much  nuclear  detritus.  None  of  these  abscesses  have 
a  definite  wall,  but  extend  directly  into  the  liver  tissue. 

II-  15.  C.  H.     OS. 247.     J.  II..  male,  age  twenty-six. 

A  n  a  t  o  m  i  C  al     Diagnosis  . — (See  Case  1. 1 

L  i  V  e  r  .—Weight  1720  gms.  Capsule  smooth.  On  section  the  markings  are 
rather  indistinct,  with  a  general  cloudy  appearance.  The  consistence  is  normal. 
Section  made  parallel  to  the  greatest  length  of  the  organ  shows  in  the  right  lobe  two 
blood-vessels  extending  completely  through  the  width  of  the  liver,  and  containing  a 
firm,  dark  red,  adherent  clot.  Running  off  from  these  two  main  vessels  are  seen 
several  smaller  vessels  showing  the  same  condition.  In  the  neighborhood  of  these 
smaller  vessels  there  are  small  areas  2  to  6  mm.  in  diameter,  of  a  reddish-brown 
color  with  small  yellowish  foci. 

Gall-bladder  . — Normal. 

M  i  c  r  o  s  c  o  pi  c  1"  x  a  m  in  ati  o  n  . — Liver-sections  show  areas  of  necrosis 
in  close  relation  to  thrombosed  vessels.  The  peripheries  of  necrotic  areas  are  in- 
filtrated with  numerous  polymorpho-nuclear  leucocytes. 


CASES    OF    LIVER    ABSCESS.  229 

III.— B.C.  H.     00.32.     M.  S.,  male,  age  forty-two. 

Anatomical  Diagnosis. — Operation  wound;  chronic-  adhesive  peri- 
tonitis right  iliac  fossa;  peri-appendical  abscess;  acute  sero-fibrinous  general  peri- 
tonitis; acute  sero-fibrinous  pleuritis.  right;  hyperplasia  and  acute  inflammatory 
softening  of  retroperitoneal  lymph  nodes;  acute  suppurative  pylephlebitis;  multiple 
abscesses  of  liver;  multiple  abscesses  of  lung;  thrombosis  of  left  spermatic  vein: 
acute  purulent  phlebitis  of  left  renal  vein  and  of  hemorrhoidal  and  vesico-prostatie 
plexuses;  ulceration  of  stomach  and  of  rectum. 

P  e  r  i  t  o  n  e  a  1  C  a  v  i  t  y  . — The  abdomen  contains  1700  cc.  of  slightly  turbid 
amber  fluid.  There  is  a  slight  fibrinous  deposit  on  the  peritoneum  in  the  pelvis. 
The  cecum  is  adherent  to  the  anterior  abdominal  wall  along  the  line  of  the  scar. 
The  appendix,  the  cecum,  and  the  beginning  of  the  ileum  are  bound  together  by 
fibrous  adhesions.  Posterior  to  the  cecum  and  appendix  is  a  small  abscess  containii  g 
thick  yellowish  pus.  The  retroperitoneal  lymph  nodes  are  much  enlarged,  and 
several  of  them  arc  completely  softened.  Along  the  spine  to  the  left  of  the  median 
line  is  a  vessel  0.75  cm.  in  diameter,  with  thickened  walls,  probably  the  left  sper- 
matic, containing  a  pale  red  thrombus,  easily  removed.  On  section  anterior  to 
the  foramen  of  Winslow,  the  portal  vein  is  seen  to  be  filled  with  yellowish  pus  and 
its  walls  considerably  thickened.  On  slitting  open  the  vein  this  condition  is  sei  n 
to  extend  downward  a  considerable  distance  along  the  attachment  of  the  mesentery. 
The  inferior  vena  cava  is  normal.  In  the  transverse  mesocolon,  along  the  pyloric 
portion  of  the  greater  curvature  of  the  stomach,  are  several  small  collections  of 
thick  yellowish  pus,  the  largest  2  cm.  in  diameter.  These  are  probably  in  veins  of 
the  portal  system.  The  lesser  peritoneal  cavity  appears  normal.  The  vessels  "I 
the  mesentery,  on  section  half  way  between  base  of  mesentery  and  small  intestine. 
appear  normal,  blood  flowing  from  the  cut  ends. 

P  1  e  u  r  a  1  Cavities  . — The  right  contains  about  300  cc.  of  turbid,  amber 
fluid.     The  left  is  free  from  fluid.     The  pericardial  cavity  is  normal. 

Lungs. — The  left  is  pinkish-gray,  deeply  pigmented  and  crepitant  through- 
out. At  the  apex,  a  few  nodules  are  felt.  On  section  the  same  color  is  presented. 
Several  dry,  caseous,  calcified  nodules  are  seen  at  the  apex;  also  several  abscesses, 
the    largest     1.5    cm.    in    diameter,    containing    a    thick,    slightly    greenish   pus. 

Stained   s ars   from   these  abscesses  show  numerous   pus   cells,   but   no  bacteria; 

in.  tubercle  bacilli  can  be  found  in  the  smears.  The  surrounding  tissue  is  paler 
than  the  remainder  of  the  lung.  The  bronchi  are  slightly  injected.  On  slitting 
open  the  veins  they  appear  normal.  The  bronchial  lymph  nodes  are  large  and 
deeply  pigmented. 

The  left  lung  presents  essentially  the  same  condition. 

Spleen. — Weight  275  gms.  Purplish-red  in  color,  and  of  about  normal  con- 
sistency.    <  >n  section  red.     Trabeculse  and  lymph  nodules  easily  seen. 

Gastr  o-intestinal  Tract.-  Stomach  filled  with  a  greenish,  opaque 
fluid,  apparently  containing  considerable  pus.  Near  the  pyloric  cud  are  two  small 
ulcers,  the  largest  1  cm.  in  diameter.  The  edges  of  these  are  elevated  and  slightly 
reddened.  ( )n  slight  compression  a  considerable  amount  of  pus  is  forced  out.  llie 
upper  part  of  the  small  intestine  contains  considerable  dark  green,  fluid  material. 
Mucosa  normal.    Appendix  G  cm.  long.    The  end  is  bulb-like,  consisting  apparently  of 


230  THE    VERMIFORM    APPENDIX   AT   AUTOPSY. 

dense  fibrous  tissue.     The  mucosa  of  the  colon  is  pale  and  unbroken.     In  the  rectum 
are  two  small  ulcers  similar  to  those  in  stomach.     Pancreas  normal. 

Liver. — Weighl  1910  gms.  Hark  brownish-red.  Here  and  there  mi  the  cul 
surface  are  groups  of  slightly  elevated,  yellow  areas,  the  largest  0.75  cm.  in  diameter. 
On  section  the  same  color  is  presented.  The  lobular  markings  are  distinct,  and  the 
interlobular  areas  are  very  pale.  Distributed  irregularly  throughout  the  liver  are 
numerous  abscess  cavities,  the  largest  aboul  2  cm.  in  diameter,  containing  thick 
slightly  greenish  pus.  Stained  smears  from  these  show  numerous  pus  cells,  but 
no  bacteria.  The  gall-bladder  is  bound  to  the  surrounding  structures  by  rather 
firm  adhesions.     It  is  small,  and  contains  thick  bile. 

K  i  d  n  e  y  S  . — Weighl  375  gms.;  they  are  smooth  and  the  capsules  strip  easily. 
The  left  kidney  is  pale,  and  the  markings  are  indistinct.  On  gentle  pressure  pus 
exudes  from  numerous  points  on  the  cut  surface,  in  the  columns  of  Bertini,  between 
the  cortex  and  pyramids,  and,  to  a  less  extent,  in  the  cortex.  Smears  show  numer- 
ous pus  cells,  but  no  bacteria.  The  pelvis  is  slightly  injected,  due  of  the  vessels, 
apparently  the  renal  vein,  is  filled  with  pus  and  its  wall  is  thickened.  A  teased 
specimen  of  cortex  shows  little  fatty  degeneration.  The  right  kidney  on  section  is 
red,  and  the  markings  distinct.      I'elvis  pale. 

A  d  r  e  n  a  1  s  . — Normal. 

B  1  a  d  d  e  r  . — Normal. 

Genital  S  y  s  t  e  m  . — The  testicles,  the  epididymes,  and  the  seminal  vesicles 
are  normal.  The  prostate  on  section  presents  a  few  ill-defined,  reddish  areas.  (  )n 
gentle  pressure,  pus  exudes  from  a  number  of  points  immediately  surrounding  the 
transverse  section  of  the  prostate,  apparently  a  cross-section  of  the  veins. 

A  o r t a  . — Intima  perfectly  smooth. 

Organs  of  the  Neck. — The  esophagus  and  the  larynx  are  normal.  The 
trachea  is  slightly  injected.  The  thyroid  is  normal.  The  lymph  glands  are  much 
enlarged  and  deeply  pigmented. 

B  r  a i  n  .—Weight  1490  gms.  The  convolutions  are  visible  through  the  dura. 
The  pia  is  not  adherent.     The  vessels  at  the  base  and  the  ventricles  are  normal. 

Cul  tu  r  e  s  . — Heart  and  Spleen-  sterile.      Liver — liver  abscess.      Portal  vein— 
Bacillus  coli  communis.     Abscess  in   transverse  mesocolon — (two  cul- 
tures),  S  t  a  p  h  y  1  o  c  O  C  C  U  S   p  y  0  g  cues   a  1  L  U  s  .     Left    kidney-     B  a  c  i  1  1  it  s 
coli   co  in  in  u  n  i  s  ,  variety  produces  no  indol  and  does  not  coagulate  milk.     Lung 
Staph  y  1  o  c  o  c  e  it  s    p  y  o  g  e  n  e  s   a  u  r  e  u  s   and   alb  u  s  . 

Microscopic  Examination  .—One  of  the  sections  of  the  kidney 
shows  a  partially  organized  thrombus  in  a  branch  of  the  renal  vein  near  the  pelvis. 
The  thrombus  contains  leucocytes,  fibrin  and  red  Mood  corpuscles.  There  are  granu- 
lation tissue  and  new  blood-vessels  extending  into  the  thrombus  from  the  wall  of 
vein  in  various  places. 

Sections  of  prostate  show  numerous  thrombi  in  vessels.  In  some  of  these  the 
thrombi  are  composed  almost  exclusively  of  pus  cells;  in  others,  of  concentric 
masses  of  fibrin  and  leucocytes.  No  organization  is  seen  in  the  thrombi,  and  no 
bacteria  are  seen  in  them  on  microscopic  examination.  The  hearl  shows  very 
slight  fibrous  myocarditis.  A  portion  of  the  wall  of  the  portal  vein  shows  an 
adherent  thrombus  composed  of  fibrin  with  beginning  organization. 


CASES    OF    LIVEB     ABSCESS.  I'M  1 

Iii  the  liver  there  are  great  numbers  of  small  and  large  abscesses,  and  in  some 
branches  of  the  portal  veins  there  are  purulenl  thrombi.  The  abscesses  represenl 
definitely  circumscribed  masses  of  pus  cells  in  fairly  good  preservation.  The  adja- 
cent liver  cells  are  compressed  and  elongated,  and  some  of  them  clearly  necrotic-. 
In  a  few  places  there  is  a  formation  of  granulation  tissue  in  the  abscess  wall.  The 
amount  of  necrosis  varies  greatly,  in  some  places  being  very  well  marked.  In  the 
liver,  at  some  distance  from  the  abscesses  there  is  very  marked  hyperplasia  of  the 
capillary  cells  -with  atrophy  of  the  liver  epithelium.  No  emboli  or  organisms  are 
found.  All  sections  of  the  liver  seem  to  show  about  the  same  condition.  The  lung 
shows  bronchitis,  atelectasis,  and  well-marked  abscesses.  The  pleura  of  the  lung 
shows  a  massive  formation  of  fibrin,  and  in  this  fibrin  there  are  circumscribed  col- 
lections of  pus  cells  similar  to  abscesses.  In  some  of  the  cells  there  appear  to  be 
a  few  short  thin  bacilli. 

The  spleen  shows  small  necrosis  with  fibrin  in  follicles.  Sections  of  the  stomach 
show  in  one  place  a  small  opening  in  the  mucosa  which  is  covered  with  pus  cells  and 
this  opening  passes  directly  downward  into  an  abscess  cavity  in  the  submUcosa. 
This  contains  pus  cells  but  no  fibrin.  No  definite  organisms  are  found.  The  wall 
of  this  abscess  is  surrounded  by  beautiful  granulation  tissue.  In  the  rectum  there 
are  acute,  deeply  undermined  ulcers,  all  of  the  same  character. 

IV.— B.  C.  H.,  I'.     00.16.     C.  H.,  male,  age  fifty-two. 

Anatomical  Diagnosis. — Operation  wound;  chronic  obliterating 
appendicitis;  acute  suppurative  pylephlebitis;  multiple  abscesses  of  liver  (?); 
chronic  adhesive  pleuritis,  right. 

In  the  right  hypochondrium  is  an  incision  5  cm.  in  length,  beginning  just  below 
costal  border.  A  gauze  drain  passes  through  this  opening  down  to  the  region  of 
the  gall-bladder  and  the  head  of  the  pancreas. 

Peritoneal  Cavity. — Contains  no  fluid.  The  omentum  is  spread  oul 
over  the  intestines,  its  lower  border  being  near  the  level  of  the  umbilicus.  The 
serosa  of  the  intestines  is  smooth,  glistening,  and  slightly  injected.  The  appendix, 
5  cm.  lone,  is  directed  inward,  its  proximal  half  bound  down  posteriorly  by  old 
fibrous  adhesions;  the  lumen  of  its  distal  half  is  completely  obliterated.  The 
mesenteric  lymph  nodes  are  not  palpable. 

P  1  e  u  r  a  1  Cavities  . — Right  lung  is  united  to  the  chest  wall  by  a  few  fibrous 
bands  passing  from  the  lateral  surface  of  the  upper  lobe  to  the  parietal  pleura. 
Left  pleural  cavity  free  from  adhesions. 

P  e  r  i  c  a  r  d  i  u  m  . — Normal,  smooth,  and  glistening. 

II  e  a  r  t  . — Of  normal  size ;  myocardium,  valves,  and  cavities  normal. 

I,u  n  gs  . — In  the  lower  posterior  portion  of  the  left  lower  lobe  there  is  a  firmer 
portion  which,  on  section,  is  found  to  consist  of  blood.  The  hemorrhage  occupies 
an  area  about  4x3  cm.  When  cut.  the  tissue  here  appears  largely  disintegrated, 
and  replaced  by  soft,  dark  blood  clots  and  blood-stained  fluid.  The  branch  of  the 
pulmonary  artery  leading  to  this  portion  of  the  lung,  when  incised,  is  found  to  be 
normal.     Lungs  otherwise  normal. 

Spleen  . — Small,  with  pale,  wrinkled  capsule :  of  sofl  (  onsistence.  <  *n  section 
it  is  pale  red.  The  lymph  nodules  are  not  visible;  but  a  little  pulp  can  be  scraped 
awav  bv  the  knife. 


232 


THE    VERMIFORM     APPENDIX    AT   AUTOPSY. 


S  t  o  m  a  c  h  a  n  <1   I  n  t  e  s  t  i  a  <•  s  .—Normal. 

Liver. — Weighl  I-'")!)  gms.  The  lower  border  does  not  extend  below  the 
costal  margin.  There  is  a  slight  amount  of  fibrin  gluing  the  neighboring  coils  of 
intestines  together  and  to  the  adjacenl  portion  of  the  liver;  bul  there  is  nowhere 
any  evidence  of  suppuration,  and  there  is  no  fluid  exudation.  The  common  bile 
duct  is  patent.  Its  mucosa  is  normal.  Its  lumen  is  not  dilated.  A  probe  readily 
]>as~cs  downward  through  the  duct  into  the  duodenum.  The  gall-bladder  is  small: 
its  wall  not  thickened:  it  contains  a  small  quantity  of  normal  bile.  The  right 
border  of  the  liver  and  the  adjacent  two-thirds  of  the  anterior  ami  posterior  surface 
of  the  right  lobe  are  dark  reddish-brown  in  color.  The  remainder  of  the  surface  is 
reddish-yellow.     The  demarcation  between   the   two  is  very  sharp.     The  portal 


Fig.  153. — Thrombus  in  Portal  Vein. 
The  left-hand  figure  shows  the  portal  vein  laid  open  and  exhibiting  a  thrombus,  Thr.,  which  extends  up  into 
the  right  branch,  /'.)'.  The  left  branch  < >f  t he  portal  vein  is  free.  S.  TO,  v.  and  /.  TO,  v.  mark  the  superior  and  infe- 
rior mesenteric  vein<.  Pa.  i-  a  snriinti  ,,f  the  pancreas.  The  right-hand  diagram  is  explanatory  <>f  the  conditions 
found,  and  shows  the  extension  of  the  thrombus  from  the  root  of  the  mesenteric  vein  through  the  portal  and  into 
the  right  branch. 


vein  is  occluded  by  a  large  red  thrombus  firmly  adherent  to  the  vessel  wall  (see  Fig. 
153).  The  diameter  of  the  portal  vein  at  this  point  is  about  1  cm.  Traced  down- 
ward toward  t he  mesenteric  roots  of  the  portal  vein,  the  thrombus  .gradually  becomes 
smaller  and  passes  into  the  sup'  rior  mesenteric  vein  for  a  short  distance.  The  lining 
of  the  lower  portion  of  the  portal  vein  and  of  the  mesenteric  vein  appears  normal. 
Within  the  liver  substance,  the  portal  vein  becomes  dilated  to  a  diameter  of  about 
1.5  cm.,  and  is  filled  with  a  dark,  grayish,  puriform  fluid.  The  liver  on  section  is 
of  normal  consistence.  The  lobules  can  be  made  out  with  difficulty.  The  branches 
of  tic  portal  vein  are  filled  with  a  rather  thick  pus.  The  walls  of  most  of  the  branches 
can  bo  made  out.  and  apparently  are  no1  involved  in  the  suppurative  process.  The 
surrounding  liver  tissue,  the  smaller  bile  ducts,  and  hepatic  artery  appear  unchanged. 
Only  a  few  branches  of  the  portal  vein  are  found  that  are  not  involved.     These  are 


CASES    OF    LIVER    ABSCESS.  233 

chiefly  in  the  left  lobe.  The  upper  portion  of  thrombus  already  described  in  the 
portal  vein  near  its  entrance  to  the  liver  has  undergone  puriform  softening. 

P  a  n  creas,  kidneys,  bladder,  aorta,  v  e  n  a  c  a  v  a  a  n  d 
hepatic    veins  . — Normal. 

A  cover-slip  preparation  from  pus  in  portal  vein  shows  a  variety  of  bacteria, 
both  bacilli  and  cocci,  some  staining,  others  decolorizing  by  Gram's  method. 

V. — B.  C.  H.,  U.     00.17.     E.,  male,  age  twenty-one. 

Anatomical  Diagnosis  . — Operation  wound ;  acute  purulent  periton- 
itis; abscess  near  appendix;  acute  suppurative  pylephlebitis;  multiple  abscesses 
of  liver;   acute  splenitis. 

In  the  abdominal  wall,  nearly  parallel  with  Poupart's  ligament,  and  about  8  cm. 
above  its  upper  half,  is  an  incised  wound,  5  cm.  long,  not  healed.  From  its  upper 
end  is  a  small  sinus  extending  nearly  1  cm.  into  the  subcutaneous  tissue.  There  is 
a  slight  purulent  discharge. 

Peritoneal  Cavit  y. — Contains  about  250  cc.  of  yellow  sero-purulent 
fluid,  rather  thin,  and  having  a  fecal  odor.  This  fluid  is  present  all  through  the  cavity, 
but  principally  in  the  upper  part.  The  peritoneum  is  dull,  and  in  places  covered 
with  shreds  of  fibrinous  exudation.  About  the  spleen  there  are  a  few  slight  fibrous 
adhesions.  The  cecum  is  firmly  bound  to  the  lateral  wall  by  fibrous  adhesions. 
After  separating  these  for  a  distance  of  about  3  cm.  the  stump  of  the  appendix  is 
found.  It  is  about  5  cm.  in  length,  and  is  closely  surrounded  by  fresh  fibrous  adhe- 
sions. Just  below  this  there  is  a  small  walled-off  pocket  containing  thick  yellow 
pus.  There  is  no  more  than  ^  cc.  of  this  pus,  smears  from  which  show  numerous 
pus  cells  and  a  few  streptococci.  Uver  the  surface  of  the  right  half  of  the  liver  are 
numerous  yellow  areas,  some  of  which  are  soft,  and  in  the  left  lobe  is  an  abscess 
cavity  of  considerable  size.  The  veins  about  the  mesentery,  the  cecum,  and  the 
lower  end  of  the  ileum  show  no  signs  of  thrombosis.  The  portal  vein  is  free  from 
thrombus  except  within  2  cm.  of  the  liver. 

Heart  . — Weight  250  gms. ;   normal.     Lungs,  normal. 

Spleen  . — Weight  ISO  gms.  There  are  a  few  fibrous  adhesions  on  the  upper 
surface  with  some  fibrin  over  the  whole.  The  tissue  is  firm;  on  section  it  is  a  dark 
red  and  moist;  the  pulp  is  increased.     The  Malpighian  corpuscles  are  very  indistinct. 

Liver  . — Weight  1980  gms.  It  extends  below  the  costal  border  for  about  6  cm. 
The  surface  is  covered  with  some  shreds  of  fibrin,  and  is  dark  bluish-red  with  vessels 
injected.  Over  the  whole  surface  are  yellow  areas,  most  of  which  are  nearly  round. 
They  vary  from  0.5  cm.  to  4  cm.  in  diameter.  About  these  yellow  areas  there  is  a 
dark,  bluish-red.  irregular  border.  In  the  upper  posterior  part  of  the  right  half. 
one  of  these  yellow  areas  is  raised  over  0.5  cm.  above  the  surface,  and  beneath  it  there 
is  considerable  fluctuation,  covering  a  space  of  5  X  7  cm.  ( )ver  the  rest  of  the  right 
half  of  the  liver  these  yellow  areas  are  slightly  raised,  on  an  average  from  2  to  I!  cm. 
in  diameter,  and  many  of  them  are  quite  soft.  Occupying  a  good  part  of  the  left 
lobe  of  the  liver  is  a  cavity,  irregular  in  shape,  about  15  X  12  cm.  in  size,  In  the 
thin  upper  wall  of  this  cavity  is  a  round  opening,  a  little  over  1  cm.  in  diameter. 
It  has  a  yellowish,  necrotic  bonier,  and  through  this  the  purulent  contents  of  the 
abscess  have  escaped  into  the  peritoneum.     On  the  under  surface  of  the  liver  these 


234  THE    VERMIFORM    APPENDIX    AT   AUTOPSY. 

abscesses  are  no1  so  numerous;  only  one  is  ruptured.  <  in  t  ransverse  section  through 
the  liver  nol  more  than  one-half  of  the  liver  tissue  is  found  normal.  The  rest  of 
tin-  area  is  occupied  by  irregular  abscess  cavities,  which  arc  a  little  more  numerous 
in  the  upper  two-thirds.  The  liver  tissue  is  dark  reddish-brown;  the  centres  of 
the  lobules  dark  red.  The  tissue  is  quite  moist,  and  near  the  abscess  walls  it  lias 
a  bluish-green  color.     The  abscesses  are  lined  with  a  thin, glistening, fibrous  wall. 

They  are   irregular  in  shape,  with  numerous  small  saccules,  many  of  which  ( i- 

municate  with  one  another.  They  contain  a  thick,  lighl  yellow,  granular  pus,  and 
numerous  small,  hard,  orange-colored  particles  of  inspissated  bile.  The  portal  vein 
as  it  enters  the  liver  is  nearly  occluded  by  a  thrombus.  This  grayish-red,  necrotic 
mass  extends  up  on  one  wall  of  the  portal  vein,  and  after  it  has  entered  the  liver 
aboul  1  cm.  there  is  a  large,  gray,  necrotic  mass  lining  the  opposite  wall.  <  >n  opening 
up  the  branches,  all  the  veins  running  to  the  liver  contain  small  thrombi,  and  a  great 
many  of  the  veins  are  found  to  communicate  with  the  abscess  cavities. 

Gall  Bla  d  d  e  r-  I-  moderately  filled  with  greenish  bile  containing  orange- 
yellow  particles.     The  gall  duct   is  normal.     The  Madder  wall  is  not   apparently 

thickened. 

Intestines,  a  d  r  e  n  a  1  s  ,  and  k  i  d  n  e  y  s  . — Normal. 

Culture  s. — Liver  abscess,  liver  tissu< — S  treptococcus  pyogenes, 
bacillus  coli  communis.  Spleen,  kidney — Bacillus  coli  com- 
munis. Smears  from  abscess  at  appendix,  portal  vein,  liver  abscess,  and  peri- 
toneum— many  pus  cells  and  streptococci. 

VI.— 15.  C.  II.     01.110.     II.  B.,  male,  age  thirty-five. 

Anatomical  Diagnosis    (see  Case  III  i. 

Mesenteric  and  Portal  Veins.— One  mesenteric  lymph  node  is 
softened,  and  contiguous  to  it  is  a  canal  (mesenteric  vein)  communicating  directly 
with  the  portal   vein,  with   roughened,  yellowish  walls  admitting  the  little  linger. 

The  i tents  of   tins  canal   i-  a  sputum-like,  yellowish,  muco-purulenl    material. 

The  portal  vein,  both  outside  and  inside  of  the  liver,  is  greatly  dilated,  and  filled 
with  the  same  material.  The  primary  branch  of  the  portal  vein  is  3  cm.  in  diam- 
eter. The  splenic  vein  contains  a  red,  rather  friable  clot.  The  hepatic,  cystic, 
and  common  ducts  are  normal  and  pervious,  as  well  as  the  gall  Madder. 

Liver.  —  Weight  171U  Lrm-.  On  the  inferior  surface  of  the  left  lobe  are  two 
small  rough  holes  3  to  4  mm.  in  diameter,  and  2  to  :!  mm.  deep;  on  pressure  yellow- 
ish, muco-purulenl  material  exudes  from  these  openings.  <  *n  section,  throughout 
the  left  lobe  the  portal  veins  are  dilated,  and  contain  yellowish, sputum-like  material. 
In  the  righl  lobe,  particularly  toward  its  superior  surface  and  toward  the  right,  are 
numerous  yellowish,  softened,  irregular  anas  arranged  in  clusters  0.3  to  0.5  cm.  in 
greatest  diameter,  tin  pressure,  material  like  that  found  in  the  portal  vein  exudes 
from  the  surface  of  these  areas.  The  intervening  liver  substance  is  brownish-red 
in  color,  and  of  normal  consistence.  The  hepatic  vein,  as  far  as  it  can  t>e  opened,  is 
normal.  The  primary  branches  of  the  portal  vein  are  much  dilated,  but  their  walls 
are  smooth.  Smear-  made  from  content-  of  the  portal  vein  show  flattened  strepto- 
cocci. 

M  i  c  r  o  s  c  o  p  i  c     Examinatio  n  . — Liver   shows    increase  of    connective 


CASES    OF    LIVER    ABSCESS.  235 

tissue  about  all  portal  spaces.  Liver  cells  do  not  stain.  At  one  cornerof  section  is  an 
area  separated  from  the  liver  substance  by  connective  tissue  containing  bile  ducts,  in 
which  are  many  cells.  These  cells  are  mostly  polynuclear  leucocytes,  many  of 
which  are  degenerated,  and  phagocytic  cells.  The  distribution  of  connective  tissue 
suggests  that  the  abscess  is  in  a  portal  -pace. 

VII  — B.  C.  II.     01.145.     T.  T.,  male,  age  seventeen. 

Anatomical  Diagnosis . — ( Operation  wounds;  localized  adhesive  peri- 
tonitis in  right  iliac  fossa;  pus  pockets  and  softened  lymph  nodes  about  cecum; 
suppurative  pylephlebitis;  multiple  abscesses  of  liver;  acute  splenic  tumor;  in- 
farction of  spleen;  acute  broncho-pneumonia  of  right  lower  lobe;  ulcers  of  colon. 

About  in  line  with  the  outer  border  of  the  right  rectus  muscle,  in  the  upper  half 
of  the  abdomen,  is  an  operation  wound  7.o  cm.  long,  in  which  can  be  seen  the  protrud- 
ing ends  of  several  iodoform  gauze  drains.  In  right  lower  quadrant  of  the  abdomen 
i-  an  oval  wound  about  2  cm.  in  length.  In  the  centre  of  this  wound  is  an  opening 
about  1  cm.  in  diameter  surrounded  by  red  granulation  tissue.  From  this  opening 
is  a  sinus  extending  down  toward  the  stump  of  the  appendix. 

P  e  ritoneal  C  a  v  i  t  y. — Contains  a  small  amount  of  clear  fluid.  Most  of 
the  peritoneum  is  smooth,  glistening,  and  free  from  adhesions.  The  mesenteric 
lymph  node-  are  enlarged,  varying  from  0.5  to  2  cm.  in  diameter,  and  are  grayish- 
pink  on  section.  About  the  above-mentioned  appendix  wound,  between  the  abdom- 
inal wall  and  the  lower  end  of  the  cecum,  are  numerous  adhesions.  Hidden  away 
in  these  is  the  stump  of  the  appendix  (operation  for  removal  about  three  -weeks  pre- 
viously). Along  the  ascending  colon,  and  particularly  between  the  hepatic  flexure 
and  the  neighboring  parts  of  the  abdomen,  jejunum,  liver,  gall  bladder,  and  stomach 
are  numerous  adhesions.  These  are  easily  broken  apart,  as  they  con-i-t  of  young 
connective  tissue  and  fibrin.  The  walls  of  the  above-mentioned  hollow  viscera  are 
also  considerably  thickened  in  this  region.  On  tearing  the  cecum  from  its  attach- 
ments, several  small  pockets  of  thick,  grayish-brown  pus  are  opened.  Behind  the 
cecum  is  a  large  lymph  node.  3  cm.  in  its  greatest  diameter,  which  has  a  caseous, 
partly  calcified  centre.  Another  node,  higher  up,  has  a  softened  purulent  centre. 
Branches  of  the  superior  mesenteric  vein,  running  from  the  lower  part  of  the  ascend- 
ing colon,  are  occluded  by  rather  friable  clots,  mottled  grayish-red  and  gray  in  color. 
These  are  only  slightly  adherent,  but  above  in  the  main  superior  mesenteric  vein, 
especially  that  portion  of  it  behind  the  pancreas,  the  clot  is  pale  in  color  and  firmly 
adherent.  The  portal  vein  contains  a  grayish-brown,  slightly  viscid,  purulent 
fluid.     Other  branches  of  the  portal  system  seem  to  contain  red  clot-. 

Pleural    and     Pericardial    Cavities  . — Normal. 

Heart. — Weight  235  gins  Myocardium  of  faded  yellow  color.  Frozen  sec- 
tion shows  marked  fatty  degeneration  of  fibres.     Coronary  arteries  normal. 

Lungs. — Downy  and  very  pale,  except  the  lower  third  of  the  right  lower 
lobe,  which  i-  red  in  color,  and  less  voluminous  as  well  as  firmer  than  other  parts. 
On  section  it  is  pale,  air  containing,  and  rather  dry  except  at  the  right  base,  which 
is  firm,  grayish-red.  and  very  slightly  granular.  The  bronchi  contain  sticky  muco- 
pus,  but  are  not  hyperemic.     The  bronchial  lymph  nodes  are  normal. 

Spleen. — Weight   2S0  gins.     Is  large,  smooth,  and  dark  red  except  at  one 


236  THE    VERMIFORM    APPENDIX     \T    AUTOPSY. 

end  over  an  area  aboul  5  cm.  in  various  diameters,  which  is  lighter  red,  with  a  few 
as  of  yellowish-gray.     On  section  the  tissue  is  dark  red.     The  Malpighian  bodies 
aiv  imt  very  distinct.     Arras  at  the  cut  end  arc  lighter  in  color,  and  there  are  pale 
areas  which  are  softer  than  other  parts  of  spleen. 

Gastro-intestinal  Tract.  Stomach  is  normal.  The  small  intest ine 
shows  many  large  area-  of  congestion  and  submucous  hemorrhages.  The  colon  is 
hyperemic.  In  the  region  of  the  hepatic  flexure  is  a  deep,  punched-oul  ulcer  about 
2  cm.  in  its  greatest  diameter.  This  has  rather  overhanging  edges,  and  its  base  is 
Formed  by  softened  necrotic  looking  tissue  suggesting  a  broken-down  lymph  node. 
In  the  connective  tissue  aboul  this  node  (if  it  i-  one)  are  several  stitches  (a1  recent 
operation  purulent  lymph  mules  in  this  region  were  incised  and  drained).     About 

s  cm.  from  this  node,  toward  the  cecum,  is  a  sec 1.  deep,  punched-out,  smaller,  Imt 

similar  ulcer. 

1'  a  n  C  r  e  a  s  . — Normal 

Liver. — Weight  1570  gms.  The  surface  i-  smooth.  On  section,  there  are 
visible  numerous  small  areas  of  bright  yellow  color  againsl  a  brownish-gray  back- 
ground, at  places  becoming  reddish.  From  many  periportal  spaces,  especially  in 
the  righl  lobe,  can  lie  squeezed  out  whitish,  creamy  pus.  Some  of  these  abscesses 
are  1  cm.  in  diameter,  lmt  the  great  majority  are  '_'  to  3.  mm.  Smears  from  this  pus 
show  leucocyte-,  and  a  smaller  number  of  slender  Gram-staining  bacilli.  The 
branches  of  the  portal  vein  at  the  hilum  of  the  liver  contain  dirty,  grayish  pus. 
('■  a  1 1  - 1)  1  a  d  d  e  r  and  d  u  c  t  s  . — Normal.     II  e  pati  c  v  e  i  n  . — Normal. 

K  i  d  n  e  y  s  ,  adrenals,  aorta  . — Normal :  no   cultures. 

II  i  c  r  o  s  c  o  p  i  c  E  x  a  m  ination  . — Heart. — .Many  fibres  show  marked 
vacuolafion. 

Liver. — There  is  a  very  extensive  necrosis;  the  liver  cells  stain  deeply  with 
eosin.  This  staining  involves  almost  the  entire  lobule,  sometimes  sparing  the  cell,-  at 
the  periphery,  sometimes  those  at  the  cent  re.  so  that  it-  point  of  origin  can  not  lie  made 
out.  Not  infrequently  liver  nuclei  are  in  process  of  indireel  division.  Most  of  such 
noted  were  at  the  periphery  of  the  lobule.  This  indicates  some  attempt  at  repair. 
In  the  capillaries  and  between  the  liver  cells  and  capillary  wall  are  seen  large  cells 
of  endothelial  character,  occasionally  in  mitosis.  In  places  running  in  from  the 
periphery  may  be  seen  several  cells  with  vesicular  nuclei  resembling  cells  of  bile 
capillaries  or  endothelium.  These  may  sometimes  separate  and  parti)'  surround 
necrotic  liver  cells.  The  divisions  can  not  be  made  out  between  the  individual 
cells  in  man)-  cases.  Mosl  of  the  liver  cells  show  large  fat  vacuoles.  In  the  peri- 
portal connective  tissue  are  numerous  polymorpho-nuclear leucocytes.  These  can 
be  traced  for  only  a  very  short  distance  into  the  liver  lobule.  Some  of  the  portal 
veins  are  filled  with  leucocytes  and  fibrin  threads.  In  the  lumen  of  some  of  the 
bile  duct-  are  polymorpho-nuclear  leucocytes.  Liver  necroses,  pylephlebitis,  acute 
suppurative  interstitial  hepatitis. 

Large  I  n  t  e  s  t  i  n  e . — Ulcer.  At  one  side  there  is  an  overhanging  edge  of 
normal  mucosa.  The  remainder  of  the  surface  is  ulcerated  to  a  varying  depth,  in 
places  to  the  submucosa,  in  other-  to  the muscularis.  The  base  of  this  ulcer  is  in  parts 
formed  by  granulation  tissue,  partially  covered  by  an  exudate  of  fibrin  and  leucocytes; 
in  parts  the  fibrin  extends  down  to  the  muscularis.     At  one  end,  in  the  granulation 


CASES    OF    LIVER    ABSCESS.  23'i 

tissue  immediately  beneath  the  fibrin,  are  many  phagocytic  endothelial  cells  with 
leukocytic  inclusions.  In  the  superficial  layer  are  numerous  intestinal  forma  of 
bacteria.     No  evidence  of  tuberculosis,  typhoid  or  amoebae  coli. 

Tin'  lymph  node  shows  fairly  normal  lymphoid  tissue  but  in  the  loose  areolar 
tissue  about  it  there  is  an  inflammatory  process — granulation  tissue  in  the  wall  of 
the  abscess.  An  artery  near  by  shows  marked  obliterating  endarteritis.  This 
node  came  from  the  region  contiguous  to  the  ulcer  in  colon.  There  is  no  evidence 
of  tuberculosis. 

VIII.— B.  C.  H.     10.185.     D.  S.,  male,  age  sixteen. 

Anatomical  Diagnosi  s. — Operation  wound ;  chronic  localized  adhe- 
sive peritonitis;  suppurative  pylephlebitis;  multiple  abscesses  of  liver;  acute 
splenitis;  infarction  of  spleen;  chronic  adhesive  perihepatitis;  chronic  adhesive 
pleuritis,  right  side. 

In  the  right  iliac  region  is  an  open  wound  with  granulating  edges,  6  cm.  in  length, 
parallel  to,  and  about  5  cm.  above.  Poupart's  ligament. 

Peritoneal  Cavity. — The  intestines  are  lustreless  and  slightly  injected 
in  places,  but  there  are  no  definite  signs  of  peritonitis.  Their  adjacent  surfaces  are 
slightly  adherent  and  easily  separated,  as  if  held  together  by  a  slighl  viscidity  of 
serosa.  Passing  through  the  operation  wound,  the  fingers  enter  a  small  walled-off 
cavity,  the  walls  of  which  are  formed  by  the  cecum,  small  intestine,  and  parietal  peri- 
toneum. In  this  pocket  is  the  stump  of  the  appendix.  The  lumen  is  patent,  and 
from  it  can  be  squeezed  brownish  fecal  material.  The  loops  of  the  intestine  forming 
these  walls  separate  with  difficulty.  The  pelvic  cavity  is  normal.  Between  the  liver 
and  diaphragm  are  numerous,  firm,  fibrous  adhesions.  Adhesions  are  also  marked 
between  the  gall-bladder  and  colon;  between  the  colon,  the  gall-bladder,  and  the 
duodenum;  ami  between  the  liver  and  the  right  kidney.  The  gall-bladder  is  dis- 
tended with  clear,  serous,  bile-stained  fluid.  The  common  bile  duct,  the  hepatic 
and  cystic  ducts  are  opened  in  situ  and  are  everywhere  patent.  The  pancreatic  duct 
is  patent  as  well.  The  liver  extends  12  cm.  below  the  tip  of  the  ensiform  cartilage 
in  the  median  line.  Over  the  anterior  surface  of  the  right  lobe  are  numerous  light 
yellow,  irregular  areas  0.5  to  1.5  cm.  in  diameter.  The  abdominal  contents  are 
removed  >  »  masse.  The  kidneys  are  dissected  out,  and  the  retroperitoneal  tissue  dis- 
sected away  until  the  portal  vein  is  reached.  The  portal  vein  is  opened  toward  the 
liver  and  in  the  opposite  direction  to  the  mesenteric  veins.  The  veins  to  the  ileocecal 
valve,  to  the  middle  point  of  the  small  intestine,  to  the  spleen,  and  to  the  stomach 
are  opened  to  the  point  of  juncture  with  each  visciis.  All  contain  a  rather  thick, 
dark,  grayish-red  fluid.  In  the  upper  part  of  the  vein  (toward  the  liver)  this  fluid 
becomes  lighter  in  color  and  more  distinctly  purulent.  The  vein  going  to  the  appen- 
dix region  differs  in  no  way  from  the  other  branches.  The  walls  of  the  veins  are 
everywhere  smooth  and  show  no  change.  The  incision  toward  the  liver  is  carried 
into  the  veins  iroing  to  both  the  right  and  left  lobes  of  the  liver.  Both  veins  are 
filled  with  blood-stained  pus.  The  hepatic  vein  and  inferior  vena  cava  are 
normal. 

The  ileocecal  and  mesenteric  lymph  nodes  are  enlarged:  the  largest  measures 
1.2  X  0.5  X  0.5  cm.    On  section  they  are  grayish-pink,  and  their  consistence  is  normal. 


238  THE    VERMIFORM    APPENDIX    AT   AUTOPSY. 

The  nodes  in  the  region  of  the  Foramen  of  Wlnslow  are  larger,  measuring  2  x  2  X  0.75 
em.     They  show  nothing  remarkable  on  section. 

L  i  v  e  r . — Weighl  3265  gms.  (after  escape  of  considerable  pus  from  abscesses). 
The  righl  lobe  is  firmly  adherenl  to  the  diaphragm  and  the  hepatic  flexure  of  colon. 
The  lefl  lobe  is  of  normal  color  and  not  adherent.  The  right  lobe  is  dark  green,  with 
numerous,  irregular,  light  yellow  patches  0.5  to  1.5  cm.  in  diameter.  <>n  cutting 
through  these  ligbl  areas,  a  creamy,  yellow  pus  exudes.  <  >u  section,  the  righl  lobe 
is  found  in  be  honeycombed  with  abscesses  of  varying  size,  the  largest  being  :!  cm. 
in  diameter.  These  abscesses  are  mosl  numerous  in  the  central  and  anterior  por- 
tions of  the  righl  lobe,  and  here  coalesce  so  as  al s1  to  form  a  single  large  cavity. 

The  extreme  right  of  the  lobe  is  free  from  them,  but  the  normal  liver  markings  cannol 
he  made  out.  In  the  left  lobe  the  suppurative  process  is  confined  to  the  veins,  which 
are  filled  with  yellowish,  purulent  material.  The  liver  tissue  encircling  the  veins 
is  soft,  and  greenish  in  color.  Smears  from  the  abscess  cavities  show  bacilli  and 
cocci,  the  latter  occurring  singly,  in  pairs,  and  in  short  chains. 

Pleural  Cavities. — The  left  lung  is  free.  The  right  lung  is  firmly 
adherent  along  its  posterior  border,  and  to  tin'  diaphragm. 

P  e  r  i  C  a  rd  i  a  1     cavil  y  . — Heart  and  lung-  normal. 

Spleen. — Weight  :'>.'!()  gms.  The  capsule  is  smooth;  the  surface  red,  with 
dark  brown,  irregular  areas.  On  section,  the  tissue  is  grayish-red  with  dark  brown 
somewhat  wedge-shaped  areas  throughout.  The  Malpighian  bodies  are  seen  as 
grayish-white,  translucent  dots,  surrounded  by  a  hyperemic  ring,  and  are  \  to  1  mm. 
in  diameter.     The  trabecule  are  indistinct;  pulp  apparently  not  increased. 

The   k  i  d  n  e  y  s ,   pa  n  c  r  •'  a  s  ,   and   g  e  n  i  t  a  1   o  r  g  a  n  s  . — Normal. 

C  u  1 1  u  r  e  s . — Heart's  blood,  lung,  liver,  spleen,  and  kidney — Strepto- 
coccus  pyogenes;    colon-like   bacillus. 

Microscopic  Ex  a  m  i  na  t  i  o  n  .  —  Liver. — Section  shows  many  small 
abscess  cavities,  the  boundaries  of  which  are  not  sharply  circumscribed,  hut  which 
show  the  leucocytes  infiltrating  more  or  less  deeply  and  irregularly  into  the  sur- 
rounding liver  epithelium.  In  a  few  of  these  anas  the  centres  are  broken  down, 
and  stain  sharply  with  eosin.  There  are  many  areas  of  congestion,  in  which  the 
red  blood  corpuscles  extend  out  between  the  liver  cells,  and  are  not  confined  exclu- 
sively to  the  capillaries.  The  portal  connective  tissue  seems  to  be  everywhere  the 
seat  of  focal  collections  of  leucocytes,  and  ill  places  the  leucocytes  can  be  seen  infil- 
trating the  space  between  the  liver  cells.  The  liver  cells  ill  these  areas  are  small, 
irregular,  granular,  and  stain  with  eosin.  Foci  of  organisms  can  be  seen  in  the 
necrotic  material  in  the  centres  of  the  abscess  cavities,  and  can  also  be  found  both 
within  and  without  cells  most  remote  from  these  area-.  In  no  place  in  the  section 
is  a  perfectly  normal  picture  presented. 

IX.— B.  C.  H.     01.188.     E.  B.,  female,  age  eleven. 

A  n  a  to  mi  c  al  1  >  i  a  Lr  nosi  s. — <  (peration  wounds;  localized  fibrinous  peri- 
tonitis righl  iliac  fossa;  pelvic  abscess;  suppurative  pylephlebitis;  multiple 
abscesses  of  liver:  acute  fibrinous  and  chronic  fibrous  pleurilis,  right  ;  atelectasis 
of  lung,  right  lower  lobe;   caseation  of  an  ileocecal  lymph  node. 

Beginning  just  below  the  costal  margin,  .j  cm.  to  the  right  and  parallel  to  the 


CASES   OF   LIVER   ABSCESS.  2311 

median  line,  is  an  open  wound.  10  cm.  in  length,  containing  a  gauze  drain  which 
extends  down  behind  the  liver.  Also  a  scar,  2  cm.  in  length,  jusl  above,  and  parallel 
to  Poupart's  ligament. 

Peritoneal  C  avit  y  .—The  serosa  appears  normal.  The  omentum  is  long 
and  devoid  of  fat.  Its  lower  end  is  bound  down  to  the  cecum  and  the  small  intestine 
in  the  appendix  region  by  easily  separable,  fibrinous  adhesions.  On  separating 
these  adhesions  a  small  pocket  is  found  containing  the  necrotic  end  of  the  appendix 
adherent  to  the  cecum.  Just  behind  this  pocket  is  a  small,  irregular  opening  into 
the  cecum,  through  which  fecal  matter  can  be  expressed.  The  tissue-  in  the  neigh- 
borhood are  necrotic.  In  the  pelvis  is  an  area  ■>  cm.  in  diameter,  including  the  pos- 
terior portion  of  the  uterus,  the  rectum,  the  broad  ligament,  and  the  adjacent  peri- 
toneum, covered  with  a  thick  layer  of  yellowish,  tenacious  fibrin.  The  mesenteric 
lymph  nodes  appear  normal  with  the  exception  of  one  in  the  ileocecal  region  which 
is  2  cm.  in  its  longest  diameter,  has  a  yellowish,  irregular  surface,  and  is  caseous. 

On  opening  the  portal  vein,  it  is  found  occluded  by  a  soft,  purulent,  adherent 
thrombus  extending  up  to  the  bifurcation  of  the  branches  going  to  the  right  and 
left  lobes  of  the  liver;  while  from  this  point  to  smaller  branches  in  the  liver,  the  vein  is 
filled  with  bile-stained,  purulent  material,  and  the  walls  of  the  vessels  are  smooth. 
The  same  suppurative  process  extends  throughout  the  upper  portion  of  the  superior 
mesenteric  vein,  and  through  its  ileocecal  branch  to  the  appendix.  Its  other  branches 
are  normal.  The  splenic  vein  is  normal,  as  are  also  its  branches,  the  gastric,  the 
pancreatic,  and  the  inferior  mesenteric  veins.  The  biliary  and  pancreatic  ducts  are 
normal. 

Pleural  Cavities. — The  right  lung  is  bound  to  its  parietes  by  fairly 
dense  fibrous  adhesions  over  the  upper  surface  of  the  lower  lobe.  On  freeing  the 
lung,  the  diaphragmatic  pleura  shows  an  irregular  area  about  3  cm.  in  diameter, 
where  the  pleura  is  ulcerated  and  covered  with  bits  of  yellow  fibrin.  Surrounding 
this  area  for  a  distance  of  3  cm.  the  pleura  is  lustreless,  granular,  and  covered  with 
a  thin  layer  of  fibrin.  The  corresponding  lung  surface  shows  a  similar  condition, 
described  below.     Left  lung  free. 

Pericardial    cavity  . — Normal.     Heart,  weight  95  gms. ;  normal. 

Lung  s. — The  left  lung  is  normal.  In  the  right,  the  lower  lobe  is  atelectatic. 
On  the  inferior  surface  of  this  lobe  is  a  ragged  ana  3  cm.  in  diameter,  slightly  covered 
with  bits  of  yellow  fibrin,  between  which  can  be  seen  pieces  of  red  lung  tissue.  This 
necrotic  process  mainly  involves  the  pleura,  but  there  is  a  slight  destruction  of  lung 
tissue.  About  this  area  for  a  distance  of  3  cm.  the  pleura  is  lustreless,  slightly 
granular,  and  covered  with  a  thin  layer  of  fibrin. 

Spleen. — Weight  70  gms.  The  anterior  surface  is  deeply  notched.  The 
capsule  smooth.  On  section  it  is  dark  red.  The  Malpighian  bodies  are  seen  as 
irregular  spheroid  dots,  surrounded  by  a  slight  hyperemic  zone.  Trabecula?  and 
blood-vessels  distinct. 

Pancreas  . — Normal. 

(I  astro-intestinal  Tract . — Throughout  the  cecum  and  for  a  short 
distance  up  the  ileum,  the  mucosa  is  thickened,  slightly  granular,  and  injected. 

Live  r. — Weight  louo  gms.  (after  drainage  of  considerable  pus).  The  surface 
is  smooth,  covered  with  innumerable  small,  gray  dots  against  a  dark  red  back- 


I'll)  THE    VERMIFORM     APPENDIX    AT   AUTOPSY. 

ground.  <  >ver  the  centre  of  the  anterior  surface  of  the  right  Lobe  this  marking  is  of 
a  greenish  hue.  <  in  the  anterior  surface  of  the  lower  part  of  the  left  lobe  is  an 
aperture,  '_'  cm.  in  length,  and  1  cm.  in  breadth,  the  edges  of  which  are  ragged  and 
covered  with  hits  of  yellow  fibrin.     (Operation  wound  for  drainage.)     <  in  section, 

both  righl  and  lefl  lobes  arc  1 eycombed  with  abscess  cavitii  s  from  0.5  to  2.5  cm. 

in  diameter,  containing  thick  yellow  pus,  which  exudes  when  they  are  cut.  The 
greater  confluence  of  these  cavities  is  in  an  area  a  little  to  the  left  of  the  centre  of 
the  righl  lobe,  involving  the  liver  substance  throughout  a  spare  as  large  as  the  hand. 
'This  appears  almost  as  one  large  abscess.  A  similar,  but  slightly  smaller  area  is  seen 
in  the  lower  posterior  portion  of  the  left  lobe. 

Between  these  abscess  cavities,  the  liver  substance  shows  a  red  background 
with  numerous,  minute,  patent  blood-vessels  around  it,  in  which  there  is  a  sharply 
circumscribed  zone,  grayish-yellow  in  color,  making  areas  \  to  ?  mm.  in  diameter. 
There  are  also  similar  areas  in  which  no  blood-vessels  can  be  made  out. 

Kidneys,   bladder,   and  genital  organs. — Normal. 

C  ul  l  u  re  s. — Heart's  blood.  liver,  and  kidney — S  t  reptococcus  pyo- 
genes,  and   colon-like     bacillus. 

II  i  c  r  o  s  c  o  p  i  c  E  x  a  m  i  n  a  t  i  o  n  . — Portal  Vein. — Intima  of  vein  has 
disappeared  and  walls  of  the  vessel  are  infiltrated  with  polymorpho-nuclear 
leucocytes  which  extend  in  large  numbers  into  the  lumen.  Mixed  with  these  are 
red  blood-corpuscles,  a  few  endothelial  cells,  and  large  cells  wilh  several  nuclei. 
Adjacent   pancreas  normal. 

Liver. — Congested.  The  liver  cells  an-  swollen,  reticulated,  and  slain  with 
eosin.  The  abscess  cavity  is  filled  with  leucocytes  and  many  granular  cells,  starting 
apparently  from  the  periportal  connective  tissue.  The  section  contains  very  little 
normal  liver  epithelium;  everywhere  are  areas  of  cell  infiltration,  or  degeneration 
and  vacuolization  of  the  liver  cells,  starting  apparently  from  the  centres  of  the 
lobules.  The  nuclei  of  many  of  the  cells  are  fragmented,  and  at  times  numbers  of 
these  fragments  are  included  in  large  pale  cells.  Small  collections  of  organisms  can 
be  seen  in  some  of  the  cells. 

I.  u  n  g  . — Section  of  the  lung  shows  marked  infiltration  of  leucocytes  into  the  lung 
tissue  for  a  short  distance ;  and  the  alveoli,  above  this,  are  crowded  together  and  show 
some  desquamation  of  lining  epithelium.  The  blood-vessels  are  everywhere  filled 
with  red  blood-corpuscles.      Leucocytes  crowd  the  periphery  of  the  vessels. 

X.— J.  H.  H.     14(19.     Female,  age  thirteen. 

A  ii  a  t  o  m  i  c  a  1  I)  i  a  g  n  o  s  i  s  .— ( Operation  wound ;  acute  gangrenous  appen- 
dicitis;  suppurative  pylephlebitis;  multiple  abscesses  of  liver;  infarction  of  kidney. 

Peritoneal  C  a  v  i  t  y  . — The  serous  surfaces  are  smooth.  Cavity  contains 
500  cc.  of  slightly  turbid,  serous  fluid.  The  appendix  lies  transversely  across  the 
psoas  muscle  and  reaches  from  it  to  the  sigmoid  flexure,  where  it  is  adherent.  The 
entire  appendix,  with  the  exception  of  the  most  proximal  portion,  is  hidden  from 
view  by  the  ileum,  near  the  ileocecal  valve.  This  part  of  the  intestine  turns  inward 
and  is  closely  adherent  over  the  appendix.  The  appendix  is  thus  covered  in  on  all 
sides  by  intestine  or  by  friable  adhesions.  It  is  necrotic  throughout  most  of  its 
extent,  and  on  separating  the  adhesions,  large  rents  appear  in  its  wall.     The  adjoin- 


ANALYSIS    OF    LIVER    ABSCESS    tasks.  241 

ing  ileum  shows  a  similar  necrosis.  The  vein  in  the  mesentery  leading  from  the 
region  of  the  appendix  is  distended  with  pus,  and  its  walls  are  in  large  part  necrotic. 
Traced  upward,  this  vessel  opens  into  the  portal  vein  behind  a  large,  partly  occluding 
thrombus.     The  other  branches  of  the  portal  system  are  normal. 

S  p  1  e  e  n. — Weight  45  gms.;  it  appears  normal. 

Kidneys. — On  the  right  there  i>  a  small,  somewhat  depressed,  deep  pink 
area,  with  a  hemorrhagic  zone  around  it.  On  section  this  extends  1  cm.  into  the 
tissue,  and  is  rather  softer  than  that  adjoining. 

L  i  v  e  r  . — Is  very  much  enlarged.  An  operation  wound  leads  into  a  cavity  in 
the  right  lobe.  The  left  lobe  extends  far  over  into  the  splenic  region.  The  liver  is 
lightly  adherent  to  the  surrounding  organs.  Its  surface  presents  many  fluctuating 
areas  which  are  surrounded  by  areas  of  congestion.  On  section  the  whole  liver,  and 
more  especially  the  large  right  lobe,  are  found  riddled  by  these  abscess  cavitiis, 
evidently  in  connection  with  the  branches  of  the  portal  vein,  and  probably  for  the 
most  part  in  direct  connection  with  them.  The  gall  ducts  are  much  dilated,  and 
probably  also  involved  in  the  infection.  The  abscess  cavities  vary  in  size  from  a 
few  mm.  to  3  cm.  They  appear  to  anastomose  freely  with  one  another. 
They  are  filled  with  thick  yellow  pus,  streaked  here  and  there  with  bile.  The  tissues 
adjoining  the  abscesses  have  the  appearance  of  deeply  congested  and  compressed 
liver  substance.     The  walls  of  the  abscesses  are  ragged  and  necrotic. 

Gall-bladder  Ducts  . — Appear  normal. 

Cultures . — Heart's  blood  and  hepatic  abscess — B  acillus  coli  com- 
m  unis, 

Analysis  of  Cases  of  Liver  Abscess. — Sex. — Of  these  10  cases,  8  were 
male,  and  2  female. 

A  g  e. — Of  the  10  cases.  5  were  under  twenty-five  years  of  age; 3  were  between 
twenty-five  and  thirty-five;  1  was  forty-two;  and  1,  fifty-two.  The  earliesl 
age  was  eleven  years. 

Condition  of  Appendix. — In  4  cases  the  appendix  had  been 
removed,  and  there  remained  only  an  appendix  stump.  In  2  cases,  the  appen- 
dices were  gangrenous.  In  2  (Xos.  I  and  IV)  the  lesion  was  so  slight  as  to  render 
questionable  its  etiological  relation  to  the  portal  process. 

Condition  of  Lire  r. — The  liver  was  enlarged  in  nearly  all  our  cases, 
and  with  two  exceptions,  it  weighed  more  than  1500  gms.  One  of  these  two, 
weighed  1000  gms.,  and  as  the  age  of  the  patient  was  only  eleven  years,  it  was 
relatively  enlarged;  while  in  the  other  case,  a  man  of  fifty-two,  its  weight  was 
1250  gms..  and  it  could  not  be  considered  as  a  liver  reduced  in  size.  The  greatest 
weight  was  3265  gins.,  occurring  in  a  patient  sixteen  years  old.  The  appearance 
of  the  liver  varies  with  the  size  and  distribution  of  the  abscess  cavities.  When 
these  are  situated  in  the  central  portions  of  the  liver,  they  give  a  mottled  appear- 
ance to  its  surface.  Against  a  background  of  fairly  normal  liver  tissue,  brown, 
brownish,  brownish-red,  yellow,  or  greenish  in  color,  the  abscess  usually  appears 
as  a  larger  or  smaller  area  of  a  lighter  hue.  generally  yellow,  but  sometimes 
greenish  from  staining  of  the  contents  by  bile,  and  often  surrounded  by  a  zone 
16 


242 


I  II  I     \  ERMIFORM    APPENDIX    AT    AUTOPSY. 


b- 


of  congestion.  These  colors  vary  with  the  character  of  the  contents  of  the 
abscess,  and  the  distance  at  which  it  lies  beneath  the  peritoneal  covering  of 
the  liver.  If  the  abscess  is  situated  immediately  beneath  the  serosa,  the 
suppurative  process  often  extends  through  the  peritoneum,  and  produces  a 
fibrinous  exudation,  a  localized  fibrinous  perihepatitis.  If  the  abscess  is  small, 
little  change  is  produced  in  the  contour  of  the  liver,  hut  larger  abscesses  produce 
distinct  bulgings  of  the  surface,  which,  in  consequence  of  increased  thinning  of 
the  tissue  between  abscesses  ami  serosa,  may  penetrate  and  discharge  their 
contents  into  the  peritoneal  cavity  (see  Case  V). 

The  cut  surface  of  the  liver  presents  different  appearances  according  to  the 
distribution  and  development  of  the  inflammatory  process.     The  intrahepatic 

portal  veins  alone  may  be  af- 
fected, and  show,  where  cut,  a 
dark  red,  firm,  adherent  clot,  as 
in  Case  II,  a  friable,  reddish- 
gray  clot,  or  fluid  puriform  ma- 
terial, as  in  Cases  IV  and  VII. 
Extension  from  the  vein  to  the 
hepatic  tissue  produces  ab- 
scesses varying  in  size  from  a 
few  millimetres  to  many  centi- 
metres. Their  contents  varies 
from  a  thin  fluid  to  a  grumous 
mass.  Their  color  depends  on 
the  admixture  of  pus  cells,  he- 
patic elements,  bile,  and  bl I. 

The  walls  may    be    smooth    or 
ragged,  and  they  are  sometimes 
lined     by     granulation     tissue. 
The   abscesses   are  round   or  ir- 
regular in  shape,  anastomosing 
along  the  course  of  the  venous  trunks,  or  showing  diverticula  due  to  the  parietal 
coalescence  of  adjacent  cavities   (see  Fig.  154).     In  the  latter  case,  very  large 
abscesses  may  be  formed,  one  of  which,  in  our  series,  measured  15  X  12  cm. 

The  abscesses,  as  a  rule,  are  multiple,  ami  scattered  throughout  the  liver, 
honeycombing  its  structures.  All  of  our  cases  showed  this  condition.  In  spite 
of  this  uniform  distribution  of  purulent  material,  however,  one  lobe  is  more 
frequently  affected  than  the  other.  In  Case  I  the  purulent  process  was  more 
marked  in  the  left  lobe,  in  Cases  VI,  VIII,  IX,  and  X,  in  the  right.  When 
the  liver  tissue  is  so  extensively  involved,  surgical  intervention  is  hopeless,  ami 
unfortunately  this  is  the  more  usual  condition,  certainly  in  the  later  stages  of 
the  infection.  There  are.  however,  two  other  types,  not  represented  in  our  series 
of  cases,  which  are  amenable  to  surgical  treatment,  and,  therefore,  of  especial 


Fig.   154. — Portal  Infection. 

.   Multiple  abscesses  of  the  liver  breaking  into  each  other.     6. 

Infiltrated  hver  tissue  in  the  neighborhood  of  the  abscesses 


ANALYSIS    OF    LIVER    ABSCESS    CASES. 


243 


■■*.-  o  - 


»« 


■>.■■ 


,V    a  .' 


♦> 


interest.  These  are  (1)  cases  in  which  the  abscess  is  single,  and  (2)  cases  in 
which  a  single  large  abscess  is  surrounded  by  groups  of  small  ones,  while  the  other 
parts  of  the  liver  are  little,  or  not  at  all  affected.  Cases  of  the  former  condition 
have  been  reported  by  Payne  (1870),  Fraxkel  (1891),  Shoemaker  (1893), 
Minro  (1902),  and  others.  Examples  of  the  latter  condition  are  given  by 
Ashby  (1879),  by  Church  (1883),  and  by  others. 

The  microscopic  picture  is  as  variable  as  the  macroscopic.  The  intralobular 
veins  are  filled  by  thrombi  or  by  pus,  with  the  walls  practically  normal  and  the 
liver  tissue  showing  no  change;  or  by  groups  of  necrotic  liver  colls  (central  or 
focal  necroses).  The  interior  of  the  veins  may  also  appear  normal,  although 
the  pathologic  process  has 
begun  to  invade  the  wall,  / 
and  the  peripheral  connec- 
tive tissue  shows  leuco- 
cytic  infiltration.  Some- 
times the  latter  condition  >. 
exists  without  the  presence 
of  thrombi  in  the  veins,  and 
there  is  then  an  acute  sup- 
purative interstitial  hepa- 
titis without  pylephlebitis 
(see  Fig.  155).  When  ne- 
crosis and  softening  begin, 
there  are  abscesses,  some- 
times confined  to  the  peri- 
portal connective  tissue, 
but  more  often  involving 
the  liver  lobules.  These 
abscesses  may  be  large  or 
small,  they  may  be  widely 
separated,  or    the  section 

may  be  thickly  studded  with  them.  The  abscess  wall  is  sometimes  formed  of 
liver  cells,  and  these  may  be  little  changed,  or  they  may  be  degenerated  and 
much  compressed;  sometimes  the  wall  consists  of  remains  of  the  periportal  con- 
nective tissue.  Reparative  changes  may  appear  in  the  shape  of  granulation  tissue 
lining  the  abscess  cavity  (see  Case  II),  which,  if  death  does  not  ensue,  eventually 
forms  adult  connective  tissue.  Liver  cells  about  the  abscess  may  be  evidence  of 
proliferation  (Case  VII ).  Degenerative  changes  remote  from  abscesses  are  gener- 
ally prominent  throughout  the  liver  parenchyma. 

Etiology. — The  pathogenesis  of  these  hepatic  suppurations  is  of  con- 
siderable interest.  How  do  the  septic  organisms  reach  the  liver  from  the 
remotely  situated  appendix?  According  to  LoiSON,  the  path  may  be  by  the 
biliary,  the  arterial,  the  venous,  the  lymphatic,  or  the  peritoneal  route.     In 


v  .-V       „-.'.•--'-  n  9<**en' 

Fig.   155. — Acute  Suppurative  Interstitial  Hepatitis    due  to 
Portal  Infection. 
a.  Liver  cells;   b,  marks  the  centre  of  an  infiltrated  portal  space;  c,  leu- 
cocyte;   d,  the  vessels. 


I'll  THE    VERMIFORM    APPENDIX    AT   AUTOPSY. 

addition  to  these  there  is  what  may  be  called  a  mixed  lymphatic  venous 
route. 

The  bile  passages  arc  an  unusual  route  for  the  extension  of  the  suppurative 
processes  to  the  liver.  Pilliet  and  Gosset,  however,  report  a  case  in  which 
they  claim  that  the  abscesses  occupied  the  bile  ducts,  and  originated  from  them, 
affording,  in  their  opinion,  an  example  of  suppuration  of  the  intrahepatic  bile 
ducts,  originating  in  the  appendix.  In  one  of  our  scries,  Case  X,  the  intra- 
hepatic ducts  appeared  to  he  involved  in  the  inflammatory  process,  hut  the 
portal  venous  system  was  evidently  the  source  of  the  liver  infection. 

The  hepatic  artery  is  a  route  by  which  it  is  evident  that  infectious  agents 
may  lie  brought  to  and  lodged  in  the  liver.  The  infection  finds  its  way  into 
the  genera]  circulation  from  the  region  of  the  appendix,  cither  by  way  of  the 
inferior  vena  cava,  or  by  the  portal  vein,  in  the  latter  case  having  passed  once 
through  the  liver  without  lodging  there.  Such  a  condition  is  part  of  a  general 
pyohemic  process,  and  is  accompanied  by  suppurative  processes  elsewhere  in 
the  body.  None  of  our  cases  belongs  to  this  group.  In  this  connection,  it  must 
be  remembered  that  general  pyemic  processes  elsewhere  may  be  secondary  to 
the  hepatic  process,  which  in  its  turn  originated  in  the  appendix. 

The  portal  system  is  by  far  the  most  important  route  of  infection,  and 
it  is  to  this  group  that  all  our  cases  belong.  By  this  path  bacteria  may 
be  transported  from  the  appendix  to  the  liver,  ami  develop  in  it  without 
affecting  the  venous  trunk.  More  frequently,  however,  septic  thrombi  form 
somewhere  in  the  course  of  the  vein,  and  we  have  a  pylephlebitis,  as  in  all  of 
our  cases.  The  septic  formation  may  happen  at  any  point  between  the  appendix 
and  the  liver,  after  which  the  process  extends  into  the  liver.  The  various 
points  at  which  such  formations  may  occur  are  illustrated  in  our  series  of  cases, 
in  which  the  portal,  superior  mesenteric,  and  appendiceal  veins  were  filled  to  a 
greater  or  less  extent  with  a  clot  or  with  fluid  pus,  the  remaining  portion  con- 
taining normal  blood.  The  other  branches  of  the  portal  system  may  remain 
free;  or  the  venous  trunk,  in  part  or  in  whole,  may  be  filled  with  puriform  material 
as  in  Case  VIII.  The  wall  of  the  vein  may  show  little  change,  or  it  may  lie  so 
extensively  involved  that  on  microscopic  examination  its  original  structure  can 
with  difficulty  be  made  out. 

According  to  Loison  the  lymphatics  of  the  appendix  do  not  communicate 
with  the  liver;  but  in  inflammatory  conditions,  either  by  means  of  adhesions 
to  the  parietal  peritoneum,  or  through  a  retroperitoneal  abscess  formation,  a 
connection  is  established  with  the  parietal  lymphatics  which  ascend  toward  the 
diaphragm  and  in  this  way  reach  the  liver.  Cases,  the  etiology  of  which  can 
be  explained  in  this  way.  are  given  by  Ki">rte  (1892),  Shoemaker  1 1893),  and 
by  PlARD  (1896).  For  none  of  our  cases  is  such  an  explanation  necessary,  but 
Case  VI II  is  suggestive  of  what  we  have  termed  the  mixed  lymphatic  venous 
route,  in  which  the  infection  is  carried  to  the  lymph  nodes  of  the  ileocecal  chain, 


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ANALYSIS    OF    LIVER   ABSCESS    (ASKS.  245 

and  here  produces  hyperplasia  and  inflammatory  softening,  thus  forming  the 
starting-point  of  the  portal  infection. 

Supra-  or  subhepatic  collections  of  pus  may  form,  and  then  extend  into  the 
liver,  forming  what  is  clinically  a  liver  abscess.  Such  a  case  may  arise  by  peri- 
toneal extension  of  the  process,  and  also  by  retroperitoneal  extension.  This 
group,  however,  belongs  more  properly  to  that  of  subphrenic  or  other  localized 
abscess. 

15  a  c  t  e  r  i  o  1  o  g  y. — The  bacteriology  of  liver  ahscess  is  the  same  as  that 
of  appendicitis.  The  organisms  present  are  those  of  the  intestinal  flora,  which 
after  reaching  the  liver  from  the  appendix  by  some  one  of  the  various  routes 
just  described,  develop  there,  with  a  resulting  abscess.  In  our  cases,  cultures 
from  the  contents  of  the  portal  vein  within  the  liver  or  from  abscess  cavities 
showed  bacillus  coli  communis  alone  in  .'>  cases,  and  combined 
with  streptococcus  pyogenes  in  4.  In  the  others  no  cultures 
were  taken,  but  in  one  of  them,  smears  made  from  pus  in  the  portal  vein  showed 
a  variety  of  bacteria,  including  both  bacilli  and  cocci. 

Two  theories  have  been  advanced  to  explain  why  liver  abscess  develops 
in  some  cases  of  appendicitis  and  not  in  others:  (1)  increased  virulence  of  the 
organisms;  (2)  lowered  resistance  of  the  liver  from  some  preexisting  lesion. 
The  first  theory  is  difficult  of  proof  in  any  given  case.  To  apply  the  second 
to  our  own  cases  is  almost  equally  so,  for  in  nearly  all  of  these,  the  liver  was  so 
extensively  involved  by  the  process  in  question  that  but  little  idea  of  previous 
lesions  could  be  entertained.  In  only  2  cases  was  there  any  evidence  of  a 
former  cirrhosis,  and  in  one  of  these  it  was  but  slightly  marked. 

The  following  additional  case  of  liver  abscess  originating  in  the  appendix  has 
been  sent  me  by  (1.  Adami  of  McGill  University,  Montreal  (see  Fig.  156): 

A.  M.,  age  fourteen,  died  April  24.  1901. 

Anatomical  D  i  a  g  n  o  s  i  s. — Thrombosis  of  the  ileocolic  branches  of  tin' 
superior  mesenteric  vein  ;  purulent  thrombo-phlebitis  of  the  portal  and  splenic  veins; 
multiple  liver  abscesses. 

P  e  r  i  1  o  n  e  a  1  Cavil  y . — The  vessels  in  the  great  omentum  are  injected  in 
the  neighborhood  of  the  wound,  but  there  is  no  evidence  of  pus  within  them.  The 
liver  reaches  7  cm.  below  the  costal  margin  in  the  right  nipple  line. 

Liver.— Dark  green  anas  are  scattered  over  the  surface.     Near  the  capsule 

on  the  dome  of  the  righl   lobe  are  1  wo  or  three  small  abscesses.      These,  however,  do 

not  project,  and  give  no  indication  of  the  suppuration  within  the  organ.  The  omental 
veins  are  normal  except  for  moderate  congestion ;  the  main,  right,  superior  mesenteric 
branches,  passing  from  the  ileocecal  region,  are  surrounded  by  swollen  and  congested 
lymph  glands.  A  fine,  dark,  apparently  adherent  thrombus  extends  along  the  vein 
up  to  its  junction  with  the  superior  mesenteric.  There  are  no  signs  of  pus  here. 
although  the  walls  are  dark  and  of  inflammatory'  appearance.  The  clot  extends 
beyond  the  junction  of  the  other  main  branches  of  tic  superior  mesenteric,  ending 
abruptly  just  above  the  point  of  junction  of  the  main  branches  of  the  vein.     In  the 


246  THE   VERMIFORM   APPENDIX    AT   AUTOPSY. 

porta]  vein,  the  clot  gives  way  to  debris  and  to  true  pus,  rather  dirty,  thin,  and  of  a 
yellowish  tinge.  Similar  matter  extends  the  whole  length  of  the  splenic  vein  into 
the  individual  branches  and  oozes  from  these  upon  sections  of  the  spleen.  The  branch 
of  the  portal  vein  going  to  the  righl  lobe  of  the  liver  is  full  of  pus;  that  going  to  the 
left  is  completely  filled  by  a  thrombus.  Here  and  there  in  the  liver  substance  this 
thrombus  gives  place  to  pus  with  abscess  formations,  which  are  most  extensive  in 
the  upper  half  of  the  righl  lobe.  The  liver  substance  is  disorganized,  and  there  are 
groups  of  abscesses  having  a  grape-like  arrangemenl  in  the  resl  of  the  righl  lobe, 
with  isolated  groups  in  the  left  lobe.  Chain-  of  swollen  glands  surround  the  portal 
vein  at  the  hiluni  of  the  liver.  Smear  preparations  of  pus  from  different  regions 
give  the  same  results  in  all  the  different  regions,  namely,  a  mixture  of  bacillary 
forms,  some  long  and  large,  others  slim,  and  others  again  short  and  in  chains. 


SPLEEN. 

Acute  appendicitis  may  produce  an  acute  splenic  tumor.  In  some  cases, 
however,  where  microscopic  examination  shows  the  changes  of  an  acute  splenitis, 
there  is  not  much  enlargement.  Abscesses  and  infarctions  may  also  occur  in  the 
spleen  as  they  do  in  other  organs. 

In  our  series  of  cases,  24  showed  an  acute  splenic  tumor.  The  proliferation 
of  epithelioid  cells  in  the  Malphigian  bodies,  commonly  found  in  diphtheria 
(Councilman,  Mallory,  ami  Pearce),  were  very  seldom  seen  in  those  of  our 
cases  which  were  studied  microscopically.  Simple  congestion  and  hemorrhage 
were  much  more  common.  The  size  of  the  spleen  varied  greatly;  anil  the 
cases  in  which  the  weigh!  was  given,  may  be  grouped  a-  follows:  Less  than 
50  gms.,  1  case;  50  to  109  gms.,  11  cases;  110  to  169  gms.,  20  cases;  170  to 
'_"_".!  -ms..  Teases;  •_>:!(!  to  '_>s'.)  gnis.,  12  cases;  200  to  349,  8  cases;  370,  and  over 
4  cases.  The  largest  spleen  weighed  600  gms.  Infarction  occurred  in  2  cases 
in  both  of  which  pylephlebitis  was  present. 

KIDNEYS. 

The  renal  lesion  most  often  associated  with  acute  appendicitis  is  a  degen- 
erative nephritis.  By  extension  from  the  region  of  the  appendix,  the  process 
may  involve  the  ureter  and  cause  an  ascending  pyelonephritis.  This  happened 
in  one  of  our  cases.  Furthermore,  if  a  general  pyemia  should  resull  from  the 
suppurative  process  at  first  localized  in  the  appendix,  metastatic  abscesses  may 
l>e  found  in  the  kidney.  Associated  with  an  embolic  process,  there  may  lie  in- 
farction of  the  kidney,  of  which  we  had  one  example,  occurrinir  in  connection 
with  acute  vegetative  endocarditis  of  the  mitral  and  the  aortic  valves. 

Beside  these  lesions,  which  are  referable  to  the  bacteria  and  toxins  proceeding 
from  the  original  process  in  the  appendix,  there  was  evidence  in  a  number  of 
cases  of  a  pathogenic  process  in  the  kidney  antedating  that  in  the  appendix. 
<>f  this  class,  there  were  12  cases  showing  a  chronic  diffuse  nephritis  of  varying 


INTESTINES.       LUNGS.       PLEURA.  247 

degree,  beside  1  with  marked  acute  and  chronic  glomerulo-nephritis.  This 
latter  case  had  shown  the  typical  symptoms  of  nephritis  for  nine  months,  and 
the  autopsy  revealed  the  above  lesions  in  a  horseshoe-shaped  kidney,  together 
with  an  associated  pelvic  abscess,  apparently  originating  in  the  appendix. 
There  was  one  case  of  renal  calculus,  and  one  of  amyloid  kidney.  In  the  other 
cases  there  was  no  chronic  renal  lesion. 


INTESTINES. 

Except  for  the  involvement  of  the  serosa  in  a  general  peritonitis  the  changes 
exhibited  by  the  intestines  are  few.  They  consist  of  congestion,  small  sub- 
mucous hemorrhages,  and,  very  rarely,  areas  of  slight  diphtheritic  exudation 
of  the  mucosa.  In  one  of  the  cases  of  appendicitis,  death  was  due  to  hemor- 
rhage from  an  eroded  vessel  in  a  duodenal  ulcer. 


LUNGS. 
In  IS  cases  the  lungs  were  congested  and  edematous;  15  showed  broncho- 
pneumonia with  varying  involvement  of  the  lung;  in  2  there  was  lobar  pneu- 
monia. The  cases  of  broncho-pneumonia  may  be  explained  in  two  ways:  (1) 
as  an  infection  from  the  appendix  by  the  vascular  route;  (2)  as  an  infection 
by  the  air  passages;  the  development  of  bacteria  thus  entering  being  favored 
by  the  condition  of  lowered  resistance  associated  with  the  appendicitis.  The 
first  is  a  true  secondary  infection,  the  second  is  of  the  nature  of  a  terminal  in- 
fection. In  4  cases,  the  lungs  were  atelectatic.  The  latter  condition  was  asso- 
ciated with  pyothorax. 

PLEURA. 

The  pleural  cavity  may  show  inflammatory  exudation  associated  with 
appendicitis,  arising  in  two  ways:  fl )  by  extension  from  a  pneumonic  focus  or 
infarct  in  the  lung;  (2)  by  extension  from  the  abdominal  cavity  by  way  of  the 
lymphatics,  or  by  erosion  of  the  diaphragm.  The  latter  form,  which  is  almost 
always  associated  with  subphrenic  abscess,  constitutes  the  "appendicular 
pleurisy''  of  some  writers,  and  it  is  almost  always  right-sided.  Some  writers 
indeed  claim  that  it  is  invariably  situated  on  the  right  side,  but  this  view  cannot 
be  accepted,  for.  as  we  have  seen,  subphrenic  abscess  following  appendicitis 
may  occur  upon  the  left  side,  and  may  be  followed  by  acute  pleuritis  on  that 
side,  as  actually  happened  in  one  of  our  cases  (see  Case  VII). 

The  appearance  of  the  pleural  cavity  varies  with  the  amount  and  the  char- 
acter of  exudation  present,  so  that  all  gradations  between  a  very  slight  fibrinous 
pleuritis  and  an  extensive  pyothorax  occur.  In  almost  all  the  cases  of  pneu- 
monia a  slight  pleuritis  was  found.  In  4  cases,  there  was  an  extensive  pyo- 
thorax. 


248  nil     VERMIFORM    APPENDIX   AT   AUTOPSY. 

HEART. 

Entrance  of  bacteria  into  the  general  circulation  may  lead  to  an  acute 
endocarditis.  This  occurred  in  '■>  cases.  All  were  cases  of  acute 
vegetative  endocarditis,  2  of  mitral,  and  1  of  mitral  and  aortic 
valves.      Preexisting    chronic    valvular    lesions    were   seen    in    .'!    cases:     in 

all    of  which    the   mitral    valve    was    affected.       In    1    there  was    stenosis,  and 

in  2  insufficiency.     In  the  former  the  aortic  valve  also  was  reduced  to  a  smaU 
triangular  opening  from  interadhesioii  and  thickening  of  the  valve  segments, 
rn  2  cases  there  was   heart    hypertrophy   without  valvular  lesion, 
referable  to  general  arterio-sclerosis  and  chronic  diffuse  nephritis. 

BLOOD  VESSELS. 

Arterio-sclerosis  is  frequently  found  at  autopsies,  especially  in 
patients  of  advanced  years,  but  it  has  no  etiological  relation  to  appendicitis, 
although  it  may  have  influenced  the  course  of  the  disease.  Thrombosis  and 
em  b  o  lis  in  may  occur  as  a  result  of  the  inflammatory  process  in  the  appendix. 
Thrombosis  of  the  portal  system  of  veins,  and  septic  em  holism 
with  abscess  formation  have  already  been  considered. 

Embolism  of  the  pulmonary  a  r  t  e  r  y  is  not  extremely  rare, 
[f  the  embolus  is  of  a  size  sufficient  to  obstruct  a  huge  branch  of  the  artery,  it 
is  rapidly  fatal.  If  it  is  not  SO  large,  and  blocks  only  smaller  branches,  infarction 
is  the  result,  which  may  or  may  not  end  fatally.  The  latter  condition  results 
from  a  thrombosis  of  the  veins,  in  the  region  of  the  appendix,  which  empty  into 
the  inferior  vena  cava.  The  thrombi,  after  formation,  become  detached  and 
entering  the  larger  vessels  are  borne  to  the  right  heart,  where  they  may  either 
lodge,  or  pass  through  \<>  stop  in  some  branch  of  the  pulmonary  artery.  This 
complication  occurs  not  infrequently  post-operatively,  of  ten  happening  incases 
which  are  running  a  perfectly  satisfactory  course,  and  forming  one  of  the  most 
unfortunate  complications  of  the  surgical  treatment  of  appendicitis. 

In  our -eiie- of  cases,  there  were  3  of  pulmonary  embolism.  In  1  of  these, 
the  occluded  branches  were  quite  small,  and  hemorrhagic  infarcts  in  the  left 
lower  lobe  (if  the  lung  had  been  the  result.  The  condition  was  associated  with 
a  chronic  valvular  lesion  of  the  left  side  of  the  heart,  and  death  was  due  to 
general  peril onit is.  In  the  oilier  2  cases,  the  main  artery  was  occluded  by 
a  large  clot,  which  occasioned  death.  In  both  cases,  the  appendix  had  been 
removed  and  the  stumps  appeared  to  be  healing,  although  a  small  abscess  was 
found  in  the  neighborhood  of  one  of  them.  In  none  of  the  cases  was  the  exact 
source  of  embolus  discovered,  though  the  veins  of  the  pelvis,  of  Scarpa's  triangle, 
and  of  the  popliteal  space  were  examined  for  evidence  of  thrombi  sis. 

Thrombosis  or  embolism  of  a  coronary  artery  is  less 
frequent.     It  happened  only  once  in  our  86  cases;  the  anterior  descending  branch 


CHRONIC    ADHESIVE    APPENDICITIS.  249 

of  the  coronary  artery  being  occluded  by  a  thrombus  in  a  case  with  acute  gan- 
grenous appendicitis,  peri-appendical  abscess,  acute  general  peritonitis,  arterio- 
sclerosis, nephroliathiasis,  and  chronic  diffuse  nephritis. 


Chronic  Adhesive  Appendicitis. 

By  this  term  is  meant  fibrous  adhesions  binding  the  appendix  to  neighboring 
structures.  These  adhesions  may  be  due  to  a  previous  inflammatory  process 
originating  in  the  appendix,  or  to  one  extending  to  the  appendix  from  adjacent 
structures  in  which  it  originated.  The  first  maybe  considered  as  p  r  i  m  a  r  y, 
the  second  as  secondary   chronic  adhesive  appendicitis. 

Frequency. — Adhesions  about  the  appendix  are  frequently  met  with 
at  autopsies,  and  in  most  of  such  cases  there  is  no  evidence  that  they  have  affected 
the  health  and  comfort  of  the  patient.  Statistics  of  frequency  of  this  condition 
vary  greatly,  but  there  can  be  no  doubt  that  adhesions  about  the  appendix  are 
so  common  as  to  indicate  that  many  people,  at  some  time  during  their  lives, 
have  had  an  inflammatory  process  involving  the  appendix,  which  has  not, 
however,  caused  any  serious  consequence. 

The  occurrence  of  fibrous  adhesions  about  the  appendix  was  investigated  in 
3770  autopsies  at  the  Boston  City  and  Johns  Hopkins  Hospitals.  (Some 
autopsies  included  in  those  observed  with  reference  to  acute  appendicitis  are 
not  utilized  because  very  incomplete  records  of  them  are  available.)  Such 
adhesions  were  found  in  325  cases,  or  8.62  per  cent.  This  percentage  is  un- 
doubtedly too  low,  and  it  is  probable  that  adhesions  were  present  in  some  cases 
not  mentioned.  In  1632  of  the  protocols  there  was  no  description  of  the 
appendix;  in  2138,  the  appendix  is  stated  to  have  been  normal,  or  a  description 
of  its  condition  is  given.  Of  the  latter  number,  15.2  per  cent,  showed  adhesions. 
The  correct  ratio  probably  lies  between  the  two. 

Ferguson  found  evidence  of  old  inflammatory  adhesions  in  only  3.\  per 
cent,  of  200  cases  examined,  while  Wallis,  in  a  collection  of  autopsies  extending 
over  five  years,  found  that  only  1.7  per  cent,  of  all  appendices  presented  evi- 
dences of  disease.  According  to  Curtis,  Finkei.stein  found  adhesions  in  7 
per  cent.,  Ransohoff  in  12  per  cent.,  and  Kracssold  and  Toft  in  I  per  cent, 
of  their  autopsies.  Robinson,  in  a  study  of  128  cases,  encountered  evidences 
of  former  peri-appendical  peritonitis  in  82,  or  04  per  cent.  Hartley  quotes 
Hektoen  as  finding  adhesions  42  times  in  280  cases,  or  15  per  cent.,  and  Matrix 
10  times  in  112.  or  14.3  per  cent.  In  "Progressive  Medicine"  for  June,  1900, 
p.  50,  it  is  stated  that  MoBurxey  in  230  autopsies  found  evidence  of  chronic 
inflammation  in  70  per  cent.  Boody  studied  528  autopsies,  finding  adhesions 
about  the  appendix  in  126,  or  24  per  cent.  These  results  differ  very  widely,  and 
do  not  justify  any  conclusions  as  to  the  relative  frequency  of  chronic  adhesive 
appendicitis. 


_'.')()  THE   VERMIFORM    APPENDIX    AT   AUTOPSY. 

S  c  \. — Of  1-7  of  these  cases,  87,  or  68.5  per  cent.,  were  males  and  40,  or 
31.5  per  cent.,  were  females.  Robinson  in  82  eases  found  65  males,  or  79.26 
per  cent.,  and  17,  or  20.73  per  cent.,  females.  Of  the  145  Boston  City  Hospital 
cases,  84  were  males;   40  were  females;   and  in  21  cases  the  sex  was  no1  slated. 

El  Lology. — Of  these  same  145  eases.   118  showed  no   evidence  of  any 
abdominal  condition  to  which  adhesions  could  be  referred,  other  than  a  prior 
inflammation  of  the  appendix,  and  they  may,  therefore,  be  considered  as  ca 
of  primary  chronic  adhesive  appendicitis  in  the  sense  stated  above;  in  27 

cases,   other    sources   for   the   adhesions   could   lie   ascertained.      Some    of    these 

must  be  regarded  as  cases  of  the  secondary  form,  while  in  others  it  was  not 
possible  to  determine  whether  the  inflammation  began  in  the  appendix  or  in 
some  other  structure,  this  being  especially  true  of  cases  associated  with  chrome 
salpingitis.  Of  these  27  cases  there  was  chronic  salpingitis  in  8,  and  in  3 
more  there  were  pelvic  adhesions  with  an  aliscess  in  Douglas's  cul-de-sac.  In 
1  case  there  was  hydrosalpinx  and  niyoinata  of  the  uterus;  in  'A,  carcinoma  of 
theuterus  with  extension  into  other  pelvic  structures ;  in 3,  disease  of  the  gall 
bladder;  in  1.  chronic  cystitis;  in  3,  very  general  adhesions  without  any  dis- 
coverable point  of  origin;  and  in  2,  tubercular  peritonitis. 


Chronic  Obliterative  Appendicitis. 

Partial  or  complete  obliteration  of  the  appendix  is  frequently  seen  at  autop- 
sies. R.IBBERT,  when  examining  400  appendices,  found  this  condition  in  25  per 
cent.;  ZUCKERKANDL  in  23.7  per  cent,  of  232  autopsies,  and  STEINEH  in  IN  per 
cent,  of  155.  In  the  records  of  the  o770  autopsies  examined  for  the  occurrence 
of  chronic  adhesions  about  the  appendix,  partial  or  complete  obliteration  of 
the  lumen  of  the  appendix  was  mentioned  in  111,  but  the  examination  of  the 
lumen  of  the  appendix  was  incomplete,  in  many  cases,  so  that  these  figures 
have  no  statistical  value.  Of  these  III  cases.  41.  or  36.9  pier  cent.,  showed 
complete  obliteration  of  the  lumen,  the  appendix  appearing  as  a  whitish  cord; 
31  of  these  showed  no  surrounding  adhesions.  Of  RlBBERT's  cases  about  .\\ 
per  cent,  were  completely  obliterated. 


CYSTS  OF  THE  APPENDIX. 
These  are  not  very  infrequent,  especially  when  small  in  size.  RlBBERT  found 
6  in  400 autopsies;  Bryant  (cited  by  Curtis),  1  in  124  autopsies;  Steiner,  3  in 
2286  autopsies;  and  BoODY,  1  in  528.  Single  cases  have  been  reported  by  a 
number  of  observers.  Wood  gives  a  case  in  which  the  cyst  was  20  cm.  in  length 
and  7  cm.  in  diameter;   lie  also  cites  19  cases  collected  from  literature,  one  of 


CONDITION    OF    APPENDIX    IX    DISEASE    OF    OTHEK   ABDOMINAL    VISCEHA.    251 

which,  that  of  McArthur,  was  situated  in  a  hernial  sac.     Wolfler  has  also 
reported  one  case  of  a  cyst  of  the  appendix  occurring  in  a  hernial  sac. 

In  o770  autopsies  at  the  Boston  City  Hospital,  16,  or  0.42  per  cent.,  cysts  of 
this  character  were  found,  besides  one  which  was  subperitoneal  and  no!  connected 
with  the  lumen  of  the  appendix.  The  latter  was  the  size  of  an  apricot,  and 
contained  clear  yellow  fluid,  resembling  the  subserous  cysts  found  elsewhere  in 
the  abdominal  cavity.  All  of  the  former  class  were  small,  the  largest  meas- 
uring 2^-  X  2  cm.  They  were  all,  with  one  exception,  formed  by  the  dilatation 
of  the  distal  end  of  the  appendix  which  was  situated  near  the  middle  of  the 
organ.     The  contents  of  one  was  a  brownish,  putty-like  mass  of  granular  debris 

and  fatty  acid  crystals;  one  showed  blackish  specks  of  extra  vasa  ted  bl 1;  the 

wall  of  one  was  green  to  blackish-green  in  color;  all  the  others  contained  colorless 
mucous,  viscid,  or  gelatinous  fluid. 


CONDITION   OF    THE   APPENDIX   ASSOCIATED   WITH    DISEASE   OF   OTHER 

ABDOMINAL   VISCERA. 

As  the  tissues  constituting  the  appendix  are  the  same  as  those  found  in  other 
portions  of  the  intestinal  tract,  as  its  lumen  normally  communicates  freely  with 
that  of  the  intestine,  and  as  its  serosa  forms  part  of  the  general  peritoneum,  it  is 
natural  to  infer  that  processes  diffusely  affecting  any  of  these  structures  would 
also  affect  the  appendix  in  the  same  manner.  In  general  this  proposition  is 
true.  However,  it  seems  advisable  to  take  up  in  slight  detail  some  of  the  more 
frequent  abdominal  diseases. 

Typhoid  Fever. — In  110  autopsies  on  typhoid  patients  at  the  Johns 
Hopkins  and  Boston  City  Hospitals,  19  showed  changes  in  the  appendix  evident 
enough  in  the  gross  to  direct  attention  to  that  organ.  The  lesions  in  these  cases 
were  various,  in  general  corresponding  to  those  produced  by  the  bacillus 
t  y  p  h  os  us  in  other  portions  of  the  intestine.  In  most  cases  the  appendix  was 
swollen,  more  rigid  than  normal,  and  its  subserous  venules  congested  locally  or 
generally.  In  a  few  cases  the  serosa  showed  a  fibrinous  exudation.  This  was 
present  in  the  cases  of  perforative  peritonitis,  but  was  also  found  when  there  was  no 
general  peritoneal  involvement.  The  mucosa  was  swollen  in  many  of  the  cases, 
and  in  most  of  these  there  was  ulceration.  The  ulceration  in  some  was  very 
superficial,  in  others  deeper,  with  sharply  defined  margins.  In  2  cases  ulcers 
had  perforated.  In  1,  almost  the  entire  mucosa  was  necrotic,  but  no  distinct 
ulcers  were  present.  In  most  of  the  cases,  the  process  closely  resembled  some 
stage  of  the  typical  typhoidal  lesion  of  the  intestine:  in  others  the  usual  form 
of  appendicitis  was  suggested.  What  part  the  b  a  cill  us  t  y  p  h  os  us  took 
in  the  etiology  of  the  lesion  in  each  case,  was  not  determined. 

Tuberculosis. — Among  our  3770  autopsies,  tubercular  lesions  were 
noted  in  the  appendix  in  44  cases,  39  of  which  showed  ulceration  extending 
from  the  mucosa  to  a  varying  depth  in  the  wall  of  the  organ.     Sometimes  the 


252  THE    VERMIFORM    APPENDIX    AT   AUTOPSY. 

wall  of  the  appendix  contained  caseous  nodules.  In  a  few  cases  ulcers  had 
perforated  and  peri-appendical  abscesses  had  formed.  In  5  cases  the  lesion 
of  the  appendix  was  pari  of  a  general  tubercular  peritonitis.  In  1  of  these 
cases  the  tubercles  were  of  the  pedunculated  variety. 

[leocolitis. — The  structures  of  the  appendix  may  participate  in  the 
pathological  process  belonging  to  the  various  forms  of  intestinal  lesions  included 
under  acute  and  chronic  ileocolitis,  as  well  as  in  those  of  the  two  diseases  just 
discussed,  and  we  may  have  swelling,  diphtheritic  exudation,  or  ulceration  of 
the  mucosa.  Among  the  cases  already  mentioned  there  is  one  of  particular 
interest   in  which  there  existed  extensive  ulceration  of  the  large  intestine  and 

of  the  appendix,  diphtheritic  inflammation  of  the  small  intestine,  and  general 

peritonitis  from  perforation  of  several  ulcers,  one  of  them  situated  in  the  ap- 
pendix.    In  both  the  intestinal  and  the  peritoneal  contents  many  amoeba;  coli 

were  found. 

.Neoplasm  s. — Metastasis  of  malignant  tumors  may  occur  in  the  appendix 
by  vascular  or  lymphatic  transportation,  or  by  implantation.  Neighboring 
neoplasms  may  involve  the  appendix  by  extension,  or  the  appendix  become 
attached  to  them  by  means  of  inflammatory  products  without  being  invaded 
by  the  tumor.  Among  our  autopsies,  in  lo  cases  the  appendix  was  invaded  by 
carcinoma,  in  1  by  sarcoma.  In  none  did  the  much  more  unusual  primary 
malignanl  growth  occur,  and  there  were  no  benign  tumors. 

Pelvic  Disease. — Very  frequently  inflammation  of  the  tubes  and 
ovaries  extends  to  and  involves  the  appendix,  and,  conversely,  inflammation  of 
the  appendix  extends  to  the  tubes  and  ovaries,  so  that  both  the  appendix  and 
pelvic  orpins  are  frequently  found  involved  in  adhesions.  In  most  cases  when 
seen  at  autopsies,  the  inflammatory  process  has  advanced  so  far  that  it  is  not 
possible  to  determine  in  which  organ  it  was  primary.  In  our  cases,  as  already 
seen  when  considering  chronic  adhesive  appendicitis,  chronic  salpingitis  and 
appendicitis  were  frequently  found  associated. 

Former  Removal  of  the  Appendix. — In  11  of  the  :!77()  autopsies, 
the  appendix  had  been  removed  during  a  previous  illness,  the  patients  had 
entirely  recovered  from  this,  ami  death  was  finally  due  to  some  cause  in  no  way 
connected  with  disease  of  the  appendix,  or  with  the  operation  for  it. 

Appendix  in  Hernial  Sac. — In  4  case-  the  appendix  was  found  in  the  sac 
of  a  hernia. 

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Berthelin:  These  de  Pari-.  1895. 
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Frankel:  Berl.  klin.  Woehenschr.,  1891,  p.  1107. 

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Hart:  X.  Y.  Presby.  Hosp.  Rep.,  1900,  p.  157. 

Hartley:  Dennis's  Syst.  of  Surg.,  1890,  vol.  4,  p.  394. 

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Kim  kowitzer  :  X.  Y.  Med.  Jour.,  1871,  vol.  13,  p.  733. 

Lang:  ''  I'elier  subphrenische  Abscesse."     I.  D.,  Moscow. 

Langheld:  I.  D.     Berlin,  1890. 

Lapeyre:  Rev.  de  chir..  1901.  torn.  23,  pp.  508,  0(0. 

v.  Leyden:  Zeitschr.  f.  klin.  Med.,  1880,  Bd.  1,  p.  320. 

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Matterstock:  Gerhardt's  Handbuch  der  Kinderkrankheiten,  Bd.  4,  Abth.  2,  p.  893. 

Maydl:  "Ueber  subphrenische  Abscesse,"  Wien,  1S94. 

McArthur:  Am.  Jour.  Obst.,  1893,  vol.  28,  p.  275. 

Munro:  Therap.  Gaz.,  1901,  vol.  17,  p.  71:  also  Bost.  Med.  and  Surg.  Jour.,  1902,  vol.  146,  p.  81. 

Xothnagel:  Spec.  Path.  u.  Therapie.  Wien,  1898,  Bd.  17,  p.  639. 

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CHAPTER  XI. 
BACTERIOLOGY. 

Chatjveatj  in  1882  demonstrated  that  the  injection  of  micro-organisms  into 
the  abdominal  cavity  might  be  followed  by  peritonitis,  and  1'awi.uwsky  in 
1887  and  1889  produced  the  condition  by  the  use  of  virulent  m  icrocoeci, 
while  Weichselbaum  in  1888  showed  that  peritonitis  might  be  caused  by 
Micrococcus  pneumoniae.  The  accurate  investigation  of  perito- 
nitis in  its  relation  to  appendicitis  may  be  said  to  have  begun,  however,  with 
Lartjelle,  who  in  1889  isolated  Bacillus  coli  from  the  exudate  in  a 
general  peritonitis  following  an  inflammatory  process  in  the  appendix.  He  was 
quickly  followed  by  E.  Frankel  (1890)  and  Predohl  (1890),  both  of  whom 
examined  a  considerable  number  of  cases  and  came  to  almost  identical  conclu- 
sion-. Frankel  found  Streptococcus  pyogenes  in  the  majority 
of  the  15  cases  which  he  examined  and  therefore  believed  that  this  organism 
played  the  chief  role  in  the  etiology  of  peritonitis,  the  other  bacteria  present 
being  secondary  invaders  from  the  intestinal  tract,  in  which  view  Predohl 
agreed,  in  spite  of  the  fact  that  he  himself  found  a  mixture  of  bacteria  in  his 
culture  tubes. 

A  year  later  I  1891  I  frankel  examined  31  cases  of  peritonitis  associated  with 
appendicitis,  and  found  Bacillus  coli,  Bacterium  aerogenes, 
M  i  c  roc  o  ecus  p  n  e  u  m  o  n  i  a  e,  and  ]\I  i  c  r  0  c  0  c  c  u  s  a  u  r  e  u  s  pres- 
ent in  addition  to  Streptococcus  pyogenes.  The  cultures  of 
Bacillus  coli  obtained  by  Frankel  proved  virulent  to  smaller  animals — 
a  fact  which  convinced  him  that  this  organism  played  no  small  part  in  the 
etiology  of  appendicitis. 

from  this  time  forward,  two  distinct  views  have  been  held  in  regard  to  the 
bacteriology  of  appendicitis,  each  being  advocated  by  accurate  observers,  and 
supported  by  careful  examinations  of  inflamed  appendices.  On  the  one  hand, 
a  number  of  bacteriologists  have  isolated  S  t  r  e  p  t  o  c  o  c  c  u  s  from  the  peri- 
toneal exudate  in  the  majority  of  their  cases,  either  alone  or  in  combination 
with  other  organisms,  and,  therefore,  they  consider  that  this  organism,  which 
is  capable  of  setting  up  most  extensive  and  virulent  inflammations  in  other 
part-  of  the  body,  as  well  as  pronounced  and  fatal  infections,  must  also  be 
responsible  for  inflammation  of  the  appendix  and  resulting  peritonitis.  On  the 
other  hand,  many  investigators  have  utterly  failed  to  isolate  Streptococ- 
cus from  the  pus  about  the  appendix,  or  in  the  general  cavity  of  the  abdomen, 
254 


MICRO-ORGANISMS    PRESENT   IX   APPENDICITIS.  -•>•> 

finding  instead  B  a  ci  11  us  coli,  or  some  other  organism  derived  from  the 
intestinal  tract,  and  as  they  are  unwilling  to  admit  that  they  have  missed 
S  tr  e  p  t  o  c  o  c  c  u  s  (although  it  is  notoriously  easy  to  overlook)  they  regard 
other  bacteria  as  the  causative  agents  in  appendicitis.  It  must  he  admitted, 
however,  that  their  views  have  received  considerable  support  from  the  fact  that 
Bacillus  c  o  1  i ,  originally  looked  upon  as  non-pathogenic,  can,  in  rare 
instances  and  in  large  doses,  produce  a  fatal  hemorrhagic  peritonitis  in  rabbits. 

A  few  of  the  more  important  investigations  bearing  on  this  question  are 
the  following:  Malvoz  found  Bacillus  coli  in  6  cases  of  peritonitis  with- 
out perforation,  and  Welch  found  it  in  3  cases  subject  to  intestinal  ulceration, 
as  well  as  in  several  cases  of  appendical  abscess.  Both  S  t  r  e  p  t  o  cocci  and 
M  i  c  r  o  c  o  c  c  i,  however,  were  found  with  the  Bacillus  coli.  In  1892, 
Jalaguier  isolated  Bacillus  coli  from  the  exudate  in  peritonitis  fol- 
lowing perforation,  together  with  M  i  cr  o  coccus  a  ur  e  us,  Bacillus 
sub  ti  lis,  and  Bacillus  lac  t  i  cus,  hut  Clado,  in  10  examinations  found 
only  Bacillus  coli.  On  the  other  hand,  K6rte  in  1892,  after  examining 
19  cases,  reported  that  hefound  Streptoco  c  c  u  s  and  M  i  c  r  o  c  o  c  c  u  s  in 
the  majority  of  them.  Tavel  and  Lanz  (1898)  investigated  24casesof  appen- 
dicitis, studying  carefully  the  different  organisms  encountered,  and  determined 
these  to  be  Bacillus  coli,  Bacillus  pyocyane  u  s ,  Bacillus 
f  e  t  i  d  u  s  liquet' aciens,  Diplococcus  intestinalis,  both 
major  and  minor,  Diplococcus  1  i  quef  a  ci  ens,  Diplococcus 
p  n  e  u  in  o  n  i  a  e,  and  S  t  r  e  p  t  o  c  o  c  c  u  s  p  y  o  g  e  n  e  s,  besides  a  bacil- 
lus  belonging  to  the  diphtheritic  group,  and  one  belonging  to 
the  glanders  group.  They  also  found  a  number  of  organisms  in  the 
microscopic  examinations  of  the  exudate  which  could  not  be  obtained  in  pure 
culture,  organisms  resembling  A  c  t  in  o  m  y  c  e  s  .  besides  Bacillus 
tetani,  some  sarcina  forms,  and  some  other  bacteria  taken  to  he 
anaerobes,  and,  as  they  found  in  several  cases  that  only  Bacillus 
coli  could  be  cultivated  out  of  a  mixture  of  different  organisms  seen  in  the 
pus,  they  concluded  that  its  importance  had  been  much  exaggerated  by 
previous  observers.  Other  important  investigations  are  those  of  Harbitz 
(1896),  who  in  14  cases  of  appendicitis  found  Bacillus  coli.  Strep- 
t  o  c  o  c  c  u  s  and  Micrococcus  ;  those  of  AcHAUD  and  Broca  (1S97),  who 
in  20  cases  found  Bacillus  c  o  1  i  alone  7  times.  Bacillus  coli  to- 
gether with  St  reptococcus,  Pneumococcus,  ami  Micrococcus 
10  times,  with  only  3  cases  in  which  Bacillus  coli  could  not  be  isolated ; 
and  those  of  Deaver  i  1898),  who  in  200  cases  found  a  mixture  of  Bacillus 
coli.    Streptococcus,    and  Mi  cr  o  c  0  c  c  u  s    usually  present. 

The  foregoing  observations  apply  only  to  the  bacteria  which  can  be  culti- 
vated by  ordinary  means,  and  which  grow  in  the  presence  of  oxygen.  The  con- 
ditions around  the  appendix  and  in  the  general  cavity  of  the  peritoneum,  how- 
ever, favor  the  development  of  pure  a  n  a  e  r  o  b  i  c  bacteria,  that  is.  bacteria 


256  BACTERI0L0G1  • 

growing  only  when  oxygen  is  excluded,  as  well  as  those  growing  indifferently 
in  the  presence  or  absence  of  this  substance,  hence,  we  should  expect  to  find 
a  considerable  number  of  bacteria  of  that  character  in  the  exudate.  There  is 
every  reason  to  believe  this  is  the  case,  but  the  only  extensive  investigation 
bearing  out  the  supposition  is  thai  of  Veillojj  and  Zi  beb  (1898),  who  in  22 
cases  of  gangrenous  and  fetid  inflammation  of  the  appendix,  found  pure 
a  ii  a  e  rob  e  s  mixed  with  B  a  c  ill  us  c  o  1  i  and  Streptococ  c  u  s  in  19 
cases.  They  determined  •">  different  species  of  a  n  a  erob  e  s,  namely  B  a c i  1- 
lus  fragilis,  Bacillus  ramosus,  Bacillus  perfringens, 
Bacillus  fusiformis,  and  Bacillus  furcosus,  which  they 
considered  responsible  for  the  gangrenous  conditions  of  the  appendix  and  for 
the  intoxication.  Finally,  Krogius  (1899)  investigated  40  cases  of  appendi- 
citis and  peritonitis,  isolating  Bacillus  coli  35  times,  Diplococcus 
p  ii  c  u  in  <>  u  i  a  c  21  times,  Diploco  ecus  in  t  es  t  inalis  <>  times, 
Streptococcus  coli  g  r  aci  1  i  s  once,  Streptococcus  p  y  o  - 
genes  once,  Bacillus  pyocyaneus  twice,  and  Proteus  vul- 
garis once.  In  7  cases  he  found  only  Bacillus  coli;  in  27  cases,  a 
mixture  of  two  or  three  different  species;  and  in  only  :!  cases  did  the  cultures 
agree  with  the  results  found  in  the  original  examination  of  the  exudate.  He 
also  found  2  species  of  a  n  a  e  robes  which  he  identified  as  the  forms  described 
by  Veillon  and  Zuber  as  Bacillus  r  a  m  os  us  and  Bacillus  per- 
fringens. 

Investigations  at  the  Johns  Hopkins  Hospital  hear  out  in  general  the  ob- 
servations of  Krogius  and  those  of  Tavel  and  Lanz,  although  some  difference 
in  results  naturally  arises  from  the  different  means  employed  for  the  identi- 
fication of  the  bacteria.  Nearly  looo  cases  of  disease  in  the  appendix  were 
examined  bacteriologically,  and  the  results  obtained  from  the  entire  series  may 
be  briefly  summarized  by  the  study  of  loo  cases  taken  quite  at  random  From  the 
surgical  records.  Thus,  in  100  cases  of  appendicitis  in  which  either  the  lumen 
of  the  appendix,  the  peri-appendical  tissues,  or  the  general  cavity  of  the  abdo- 
men was  examined,  the  St  ropl  ncoccus  was  found  in  only  hi  cases,  while 
Bacillus  c  o  1  i  was  present  in  NO.  Bacillus  1  a c t i s  a  e  rogenes 
was  obtained  in  10  cases,  and  members  of  the  hog  cholera  group  in  10 
cases.  Bacillus  pyocyaneus  was  found  in  2  cases,  Bacillus 
f  e  c  a  1  i  s  a  1  c  a  1  i  g  e  n  e  s  in  ■'!.  P  r  o  tens  vulgaris  in  4,  and  Bacil- 
lus ae rogenes  capsulatus  of  Welch  in  4  cases.  In  the  majority 
of  the  cases,  several  species  of  organisms  were  isolated  side  by  side,  no  matter 
whether  the  lumen  of  the  appendix  only  was  examined,  or  a  localized  peritonitis 
around  the  appendix,  or  a  general  inflammation  of  the  serous  membranes. 

This  brief  summary  of  evidence  makes  it  plain  that  the  results  obtained 
by  different  investigators  on  this  subject  are  remarkably  in  accord,  taking  into 
consideration,  of  course,  that  the  experiments  were  carried  on  in  laboratories 
situated  in  countries  widely  separated  by  distance,  and  by  bacteriologists,  each 


CONDITION'S  FAVORING  DEVELOPMENT  OF  MICRO-ORGANISMS  IX  APPENDIX.    251 

of  whom  employed  a  technic  characteristic  of  his  own  laboratory.  This  striking 
agreement  is  accounted  for  by  the  fact  that  the  conditions  existing  in  the  cecum 
and  appendix  are  practically  uniform,  not  only  in  the  normal  state  of  the  organs, 
but  even  when  the  appendix  is  attacked  by  disease,  or  affected  by  the  sequelae  to 
inflammation  of  it.  We  believe  that  the  bacteria  found  in  inflammatory  con- 
ditions of  the  appendix  are  present  in  the  normal  intestinal  tract,  in  all  cases, 
except  those  rare,  and  not  well  authenticated  instances,  when  appendicitis 
develops  during  the  course  of  an  infectious  disease,  a  condition  under  which  it 
has  been  stated  that  inflammation  in  the  appendix  may  lie  set  up  by  the  organ- 
isms causing  the  original  infection. 

The  cecum  is  the  point  which  offers  the  very  best  conditions  in  the  entire 
intestinal  tract  for  the  development  of  bacteria.  In  the  stomach,  organisms 
taken  from  the  external  world  find  a  medium  too  highly  acid  for  their  rapid 
multiplication;  in  the  small  intestine,  bacteria  meet  with  insufficient  pabulum 
to  sustain  life;  therefore,  it  is  only  when  the  ileocecal  valve  is  reached  that  we 
find  conditions  allowing  an  abundant  development  of  micro-organisms.  Here 
the  reaction  is  favorable  to  the  growth  of  bacteria,  and  sufficient  undigested 
food  is  present  to  supply  the  nutriment  necessary  to  their  increase.  Not  only 
are  plates  taken  from  this  region  thickly  crowded  with  colonies,  but  the  greatest 
diversity  of  the  forms  cultivated  is  thus  obtained,  even  under  ordinary  methods 
of  isolation.  By  special  technic  the  number  of  different  bacteria  found  in  the 
ileocecal  region  may  be  greatly  increased,  the  number  of  bacteria  in  diseased 
conditions  of  the  bowel,  even  in  normal  conditions,  being  always  much  aug- 
mented. By  direct  continuity,  the  bacteria  spread  from  the  cecum  to  the 
lumen  of  the  appendix,  in  which  the  flora  is  identical  with  that  of  the  cecum, 
so  far  as  the  varieties  of  micro-organisms  are  concerned.  Hence,  we  have  the 
most  favorable  conditions  for  the  rapid  development  of  bacteria  through  to 
the  walls  of  the  appendix,  and  the  initiation  of  an  inflammatory  process, 
the  limitations  of  which  will  be  largely,  although  not  entirely,  determined  by 
the  virulence  of  the  invading  micro-organisms.  The  following  species,  in  our 
estimation,  are  of  greatest  importance  in  initiating  and  extending  inflamma- 
tions of  the  appendix. 

Streptococcus  pyogenes  (Rosenbach,  1 8S4).  —  This  organism  can  be 
isolated  in  only  the  minority  of  cases  of  appendicitis;  nevertheless,  it  must  be 
considered  as  of  the  greatest  importance  etiologically  in  the  causation  of  the 
disease.  It  is  especially  associated  with  all  cases  of  very  severe  infection,  and 
is  the  usual  cause  of  extensive  and  rapidly  fatal  peritonitis.  It  is.  however,  an 
organism  somewhat  difficult  to  cultivate  artificially,  even  when  present  in  pure 
culture,  and  when  associated  with  other  micro-organisms  it  is  often  overgrown 
by  bacteria,  which,  although  more  viable,  are  not  more  virulent.  Its  colonic-, 
which  are  small  and  almost  transparent,  are  easily  missed  in  examining  both 
agar  and  gelatin  plates.  It  is.  however,  a  normal  inhabitant  of  the  intestinal 
tract,  especially  the  portion  of  the  cecum  near  the  appendix.  The  Strepto- 
17 


258  B  \i   I  'ERIOLOGY. 

cocci  arc  organisms  possessing  great  variability  in  virulence,  some  s|iccies 
being  capable  of  setting  up  rapidly  fatal  infections,  while  others,  on  the  con- 
trary, limit  their  pathogenic  action  to  the  production  of  local  abscesses.  It 
is  impossible  to  estimate  the  virulence  of  any  given  species  without  extensive 
animal  experimentation,  but  its  demonstration  in  the  pus  of  appendicitis  must 
be  invariably  regarded  as  of  the  gravest  prognostic  significance.  Morpho- 
logically, it  is  apt  to  grow  in  the  tissues  simply  as  a  d i  pi o c  o  c  c  u  s  or  as 
short  chains,  only  assuming  its  characteristic  appearance  alter  several 
generations  on  artificial  media. 

Bacillus  coli  communis  (Bacillus  coli,  Migula,  L900). — This  organism, 
originally  discovered  by  Escherich  in  the  dejecta  of  infants,  has  since  been 
shown  by  numerous  observers  to  exist  normally  in  the  intestinal  tract  of  man, 
as  well  as  to  have  a  wide  and  extensive  distribution  in  Nature.  Morphologically, 
it  appeals  as  a  small  plump  bacillus,  slowly  motile,  and  possessing  universal 
fiagella.  It  is  easily  cultivated  on  all  artificial  media  in  the  laboratory,  growing 
abundantly  as  a  whitish-yellow  deposit  on  surface  of  solid  media,  always  acidify- 
ing and  coagulating  milk,  and  breaking  up  the  carbohydrates  with  the  evolution 
of  acid  and  gas,  but  not  liquefying  any  proteid  material.  Originally  supposed  to 
be  lacking  in  any  pathogenic  action,  it  has  now  been  shown  to  possess  consider- 
able virulence — its  various  species  differing  greatly  in  this  respect.  Intravenous 
and  intraperitoneal  injection  of  large  doses  will  kill  smaller  animals,  and 
epidemics  among  them  have  been  found,  in  many  cases,  to  be  caused  by  organ- 
isms differing  in  no  essential  particular  from  typical  cultures  from  the  intestinal 
tract  of  man.  Certain  species  of  B  a  c  i  1 1  u  s  coli  are  especially  prone  to  set 
up  hemorrhagic  peritonitis,  and  its  pus-producing  properties  have  long  been 
recognized  by  observers  who  have  found  it  in  superficial  abscesses,  it  having 
been  originally  described  in  this  location  as  B  a  ci  11  u  s  p  y  o  g  e  n  es  fet- 
id us.  It  occurs  in  the  pus  of  general  peritonitis,  in  abscesses  around  the  ap- 
pendix, ami  in  its  lumen;  sometimes  in  pure  cultures  and  sometimes  mixed 
with  other  micro-organisms.  It  is  the  most  common  secondary  invader  in  all 
cases  of  appendicitis  and  peritonitis  caused  by  the  S  t  r  e  p  I  0  c  o  c  c  u  s  or  by 
other  organisms,  and  it  may  have  an  exalted  virulence,  when  associated  with 
other  bacteria.  Not  only  can  Bacillus  coli  be  obtained  from  those 
cases  in  which  other  and  more  virulent  bacteria  are  found,  but  in  a  large 
number  of  cases  it  is  the  only  species  which  can  be  isolated.  In  these  cases 
the  microscopic  examination  of  the  exudate  is  confirmed  by  the  cultural  experi- 
ments, and  no  evidence  exists  to  show  that  the  Streptococcus  was 
present  and  was  overlooked.  Moreover,  the  type  of  the  disease  in  these  cases  is 
much  milder  than  in  those  in  which  Streptococci  are  found,  the  inflam- 
mation being  often  limited  to  the  tissues  in  the  immediate  vicinity  of  the 
appendix,  the  resulting  peritonitis  being  less  extensive  and  less  severe,  besides 
manifesting  a  greater  tendency  to  the  formation  of  localized  abscesses,  with 
the  production  of  large  quantities  of  pus  of  a  peculiarly  fetid  character. 


MICRO-ORGANISMS    PRESENT    IX    APPENDICITIS.  259 

Bacillus  pyocyaneus  (Pseudomonas  aeriginosa,  Migula,  1900). — This 
organism,  known  for  a  long  time  as  the  "  bacillus  o  f  b  1  u  e  p  us,"  occurs 

in  the  contents  of  the  intestinal  tract  in  a  large  number  of  cases,  in  so  many, 
indeed,  that  it  may  be  looked  upon  as  a  normal  constituent  of  the  alimentary 
canal.  Morphologically,  it  is  a  very  small,  actively  motile  bacillus,  charac- 
terized by  its  imparting  to  all  culture  media  a  green  color,  now  known  to  be  due 
to  the  production  of  the  pigments  rluorescin  and  pyocyanin.  It  is  easily  culti- 
vated in  all  satisfactory  media,  and  is  separated  from  the  other  fluorescent 
organisms  by  its  ability  to  break  up  proteid  material,  such  as  gelatin,  casein, 
and  blood  serum,  causing  their  complete  liquefaction,  and  also  by  its  inability 
to  split  up  carbohydrate  solutions.  It  is  possessed  of  considerable  pathogenic 
properties.  When  introduced  into  the  genito-urinary  system  it  may  set  up 
extensive  infections,  ascending  from  the  bladder  to  the  ureters  and  kidneys,  or 
it  may  invade  the  body  through  a  superficial  lesion  of  the  intestinal  mucosa 
and  originate  a  systemic  infection  with  fatal  outcome.  Experimentally, 
Bacillus  pyocyaneus  can  occasion  an  extensive  hemorrhagic  and 
fibrino-purulent  inflammation  of  the  peritoneum,  rapidly  causing  death  when 
introduced  into  the  abdominal  cavity  of  smaller  animals.  There  is  a  small 
number  of  cases  in  which  its  relation  to  appendicitis  has  been  well  demon- 
strated, but  it  has  been  reported  in  this  connection  only  a  few  times,  and  at 
the  Johns  Hopkins  Hospital  it  is  found  to  be  one  of  the  rarer  pathogenic  agents 
encountered  in  this  disease.  It  is  possible  that  it  originates  inflammatory 
processes  in  the  appendix,  but  more  probably  it  is  a  secondary  invader  of  struc- 
tures already  diseased. 

Bacillus  proteus  vulgaris  (Bacillus  vulgaris,  Migula,  1900). — Proteus 
forms,  including  several  distinct  species,  are  normally  found  in  the  intestinal 
tract  and  occasionally,  though  rarely,  in  the  pus  around  the  appendix,  as  well 
as  in  peritonitis.  They  are  easily  recognized  on  the  surface  of  agar  and  gelatin 
by  their  characteristic,  spreading  colonies.  Experimentally,  these  bacilli  can 
originate  extensive  inflammation  of  the  peritoneum  in  smaller  animals,  resulting 
in  death,  but  their  pyogenic  properties  in  man  are  still  problematic.  They  are 
rarely  met  with  alone  in  appendicitis,  being  usually  associated  with  other  bac- 
teria. It  is  probable  that  they  seldom  initiate  the  morbid  process  in  the  appen- 
dix, but,  like  many  other  intestinal  bacteria,  they  travel  through  a  ruptured 
intestinal  wall  in  the  wake  of  more  actively  pathogenic  agents. 

Micrococcus  pyogenes  (Micrococcus  aureus,  Migula,  1900). — The  Micro- 
cocci, or  as  they  are  usually  called,  the  Staphylococci,  occur  but 
rarely  in  the  inflammation  of  the  peritoneal  cavity.  Morphologically,  they 
appear  as  collections  of  spherical  organisms,  whose  tendency  to  assemble  in 
groups  like  bunches  of  grapes  gave  them  their  original  appellation.  They  are 
easily  cultivated  artificially,  but  they  may  be  recognized  by  their  characteristic 
appearance  under  the  microscope.  Many  species  are  possessed  of  great  virulence, 
especially  the   "golden     yellow    coccus."   and   when  associated  with 


260  BACTERIOLOGY. 

other  bacteria,  especially  the  Strep  tocacci,  they  may  give  rise  to  the 
collections  of  pus  often  seen  about  an  inflamed  appendix.  They  rarely  cause 
a  general  peritonitis,  but  when  present  in  pure  culture,  thej  generally  confine 
their  pathogenic  action  to  the  peri-appendical  tissues. 

Pneumococcus  (Diplococcus)  (Streptococcus)  (Micrococcus  pneumoniae, 
Weichselbaum,  1888). — In  our  opinion  this  organism  plays  a  very  doubtful 
role  in  the  etiology  of  appendicitis  and  appendical  peritonitis.  It  has  been 
reported  as  present  by  a  number  of  observers,  notably  by  Krogius,  who  has 
contributed  the  most  extensive  series  of  cases ;  but  the  grounds  for  its  identifica- 
tion are  imi  always  of  the  soundest.  It  closely  resembles  St  repto  coccus 
in  its  cultural  reactions,  as  well  as  in  its  colonies  on  agar  ami  gelatin,  but  it  can 
he  positively  identified  only  by  the  definite  demonstration  of  a  capsule,  or  by 
positive  criteria;  organisms  which  resemble  the  Pneumococcus  should 
usually  he  classed  as  S  t  r  e  p  t  o  c  o  c  c  i .  In  an  experience  extending  over  a 
decade  in  the  laboratory  of  the  Johns  Hopkins  Hospital,  there  have  been  3 
cases  in  which  Micrococcus  pneumoniae  was  undoubtedly  the 
cause  of  peritonitis,  and  not  one  of  these  was  the  result  of  appendicitis.  The 
Pneumococcus,  moreover,  does  not  occur  ordinarily  m  the  contents  of 
the  cecum.  Taking  all  these  facts  into  consideration,  its  importance  in  the 
etiology  of  appendicitis  becomes  minimized.  In  rare  instances  it  may  reach 
the  appendix  from  the  lungs,  being  carried  there  by  the  blood  stream,  and  in 
that  event  it  may  cause  inflammation  of  the  organ. 

Bacillus  lactis  aerogenes  (Bacterium  aerogenes,  Migula,  1902). — This 
organism  is  the  capsulated  bacterium  normally  present  in  the  intestinal  tract  of 
all  individuals.  lis  cultural  reactions  are  identical  with  those  of  the  B  a  cil  lus 
col  i,  with  which  it  is  usually  associated.  Morphologically,  it  is  a  thick,  plump 
bacillus — non-flagellated — the  growths  of  which  on  ordinary  media  are  viscid 
and  stringy:  it  is  frequently  found  in  the  pus  about  an  appendix,  or  in  the 
general  cavity  of  the  abdomen,  but  it  possesses  no  pathogenic  properties  for 
man,  although  in  enormous  doses  it  has  a  fatal  effect  on  animals.  When  isolated 
in  typhlitis  it  has  no  significance. 

Bacillus  alcaligenes  (.Migula,  1900). — This  organism,  originally  de- 
scribed  by  Petrevsky,  as  Bacillus  f  e  c al i s  alcaligenes,  is  present 
in  practically  every  individual,  although  in  relatively  small  numbers.  It  is  of 
importance  chiefly  from  its  great  resemblance  to  Bacillus  typhosus, 
from  which  it  is  distinguishable  only  by  its  failure  to  act  upon  any  carbohy- 
drates, and  by  its  intense  alkali  production  in  litmus  milk.  Like  Bacillus 
lactis  aerogenes,  it  is  of  no  pathogenic  importance,  as  its  cultures  are 
quite  devoid  of  toxic  action. 

Bacillus  of  the  Hog  Cholera  Group. — Organisms  belonging  to  this 
group,  originally  described  as  intermediate  in  character  between  Bacillus 
t  y  p  h  o  s  u  s  and  Bacillus  c  o  1  i ,  were  early  recognized  by  WELCH, 
Salmon-,  and  Smith  in  this  country,  ami  by  numerous  observers  abroad.     The 


MICRO-ORGANISMS   PRESENT    IX   APPENDICITIS.  261 

number  of  species  included  in  this  group  is  very  large,  and  all  of  them  are  pos- 
sessed of  marked  pathogenic  properties.  Among  them  may  be  mentioned 
Bacillus  suipestifer,  or  the  Hog  cholera  bacillus,  Ba- 
cillus enteritidis  of  Gaertxer,  Bacillus  Breslaviensis 
of  Gaffky  and  Paak,  Bacillus  morbificans  b  o  vi  s  of  Base- 
NAU,  the  various  paracolon  bacilli  isolated  in  France  and  in  America, 
and  the  "  p  a  r  a  t  y  p  h  o  ids"  obtained  in  Germany.  Members  of  this  group 
occur  frequently  in  the  normal  intestinal  tract,  and  are  present  in  about  10  per 
cent,  of  all  cases  of  appendicitis.  Without  extensive  investigation,  it  is  diffi- 
cult to  determine  to  which  particular  species  any  given  organism  should  be 
assigned,  and  it  is  correspondingly  difficult  to  estimate  with  any  certainty 
the  role  which  they  take  in  appendicitis.  Their  pathogenic  action,  however, 
is  very  marked,  and  their  importance  is  probably  much  greater  than  is  gener- 
ally supposed. 

Bacillus  aerogenes  capsulatus  (Bacterium  Welchii,  Migula,  1000). — This 
strictly  anaerobic  organism,  originally  described  by  Welch  and  Nuttall  as 
the  "Gas  bacillus"  (Bacillus  aerogenes  c a  p  s u  1  a t  u s),  has 
since  been  recognized  in  a  number  of  countries  as  having  a  wide  distribution. 
It  was  described  in  Germany,  by  Frankel  as  B  a  c  i  1 1  u  s  p  hi  eg  m  ones 
e  m  p  h  y  sematosae,  in  England,  by  Klein  as  Bacillus  enteriti- 
dis sporogenes;  anil  the  organism  described  as  Bacillus  perfrin- 
gens  by  Veillon  and  Zuber  is  evidently  the  same  species.  The  recognition 
of  a  relationship  between  this  organism  and  appendicitis  has  already  been  men- 
tioned in  the  consideration  of  Veillon  and  Zuber 's  investigations.  It  has  been 
shown  by  Welch  to  have  an  almost  universal  distribution  in  the  intestinal  tract 
of  man,  as  well  as  in  that  of  most  of  the  lower  animals,  and  its  constant  presence 
in  the  lumen  of  the  appendix  has  been  demonstrated  by  Yates.  It  is,  however, 
an  organism  requiring  special  methods  of  isolation  in  pure  culture,  although 
its  morphology  as  a  long,  straight  bacterium,  surrounded  by  a  capsule  and  re- 
taining Gram's  stain  well,  frequently  demonstrates  its  presence  in  a  mixture 
with  other  organisms.  It  acts  as  a  cause  of  general  peritonitis  very  rarely, 
and  is  usually  considered  to  invade  only  tissues  already  diseased.  It  has, 
however,  been  found  in  a  number  of  cases  of  appendicitis,  including  one  asso- 
ciated with  a  severe  and  rapidly  fatal  case  of  general  peritonitis. 

BIBLIOGRAPHY 
FROM    KROGIUS. 

Achavd  f.t  Broca:  " Bacteriologie  dp  vingt  cas  d'appendicite  suppuree."     Bull.  ei  mem.  de  la 

Soc.  iih'-.1.  des  hopit.  de  Pari-,  1V>7.  p.  142. 
CiivrvEAr:  "  Sur  la  septicemic  puerperale  exp&imentale."     Lyon  meet.,  1882,  torn.  41,  p.  272. 
Clado:  "Appendice  coecal,  etc."     Mem.  de  la  Soc.  'If  biol.,  1892,  p.  133. 
Deaver:  "  Remarks  upon  tin-  differential  diagnosis,  pathology,  and  treatment  of  appendicitis." 

Ann.  Sun:..  1898,  vol.  27.  p.  303. 
Frankel,  E.:  "Zur  Atiologie  der  Peritonitis."     Munch,  mod.  Wochenschr.,  1890,  p.  23. 


262  ii\(  ii:i:ioi.O(iv. 

Harbitz:  "(tin  appendicitens  pathologiske  Anatomi  og  Aetiologie."     Norsk  Mag.  for  Laegi 

idenskaben,  1896,  p,  Mil . 
Jalagi  ier:  "Resultats  de  I'examinen  bactexiologique  'In  pus  d'une  peritonite  generalises  par 

perforation  de  1'appendice  Ueo-ccecal."     Bull.  e1  mem,  de  la  Soc.  de  chir.,  L892,  torn.  18, 

p.  391. 
K"i  1 1  :  "  Erfahrungen  iiber  die  chirurgische  Behandlung  der  allgemeinen  eitrigen  Bauchfellent- 

zundung."      \nli.  f.  Klin.  Chir.,  1v>l>,  Bd.  4  1.  p.  612. 
Krogius:  "Om   appendiciternas  bakteriologi."      Finska   Lakares&llskapets  handlingar,    1899, 

P.  1198 
Malvoz:  "Li-  bacterium  coli  commune  comme  agenl  habitue!  <  1 « - -~  peritonites  d'origine  intesti- 

nale."     Arch,  de  im'il.  experim.  «■(  d'anat,  path.,  1891,  p.  593 
Pawlowski  :  "  Beitrage  zur  Atiologie  und  Entstehungsweise  der  akuten  Peritonitis."     Centrbl. 

f.  Chir.,  1887,  p.  ssi 
—  "  Zur  Lehre  von  der    Uiologie  und  den  Formen  der  akuten  Peritonitis."     Virchow's  Archiv, 

1899,  Bd.  117.  p.  169. 
Predohl:  " Untersuchungen  zur    Uiologie  <1<t  Peritonitis."     Munch,  med.  Wochenschr.,  1890, 

p.  22. 
Tavel  and  Lanz:  "Ueberdie  Atiologie  der  Peritonitis."     Mittheil.  a.  klin.  u.  med.  [nst.  der 

Schweiz,  1893,  1-  Reihe,  1.  Heft. 
\  in  1 1 1 n  m  V.\  ber:  "  Recherches  sur  quelques  microbes  strictement  anaerobies  e<  Ieur  role  en 

pathologie."     Arch,  de  m£d.  exp.  et  d'anat.  pathol.,  1898,  p.  ">17. 
Weichselbaum :  "Der  Diplococcus  Pneumoniae  als  Ursache  der  prim&ren  akuten  Peritonitis." 

Centralbl.  f.  Bakteriologie,  1888,  p.  33. 
Welch:  "The  bacillus  coli  communis:  the  conditions  of  its  invasion  of  the  human  body,  and 

ii-  pathogenic  properties."     Med.  News,  1891,  vol.  59,  p.  669. 


CHAPTER    XII. 
PATHOLOGY. 

acute  catarrhal  appendicitis.    acute  diffuse  appendicitis.   chronic 
ulcerative  and  purulent  appendicitis. 

Acute  Appendicitis. 

It  is  only  by  means  of  observations  made  at  operations  and  at  autopsy,  accom- 
panied by  examinations  of  each  case  in  detail,  that  we  can  construct  a  general 
picture  representing  the  pathological  changes  taking  place  in  inflammations  of 
the  appendix  in  their  beginning  and  development,  as  well  as  the  relation  be- 
tween the  etiology  of  appendicitis  and  its  pathological  anatomy.  In  the  course 
of  a  routine  examination  of  all  specimens,  many  important  conditions  are  dis- 
covered, and  the  pathological  changes  underlying  the  causation  of  an  attack 
of  acute  appendicitis  become  apparent. 

The  custom,  which  has  become  general  during  the  last  few  years,  of  early 
operation  in  appendicitis,  as  well  as  of  operation  a  jroid,  affords  the  opportunity 
essential  to  studying  these  various  lesions  in  their  inception,  their  develop- 
ment, and  their  final  outcome.  The  views  expressed  and  the  conditions  de- 
scribed in  the  following  pages  embody  results  obtained  from  a  study  of  all  the 
material  furnished  by  the  gynecological  and  surgical  departments  at  the  Johns 
Hopkins  Hospital,  as  well  as  by  its  postmortems,  and  by  a  large  number  of 
interesting,  and  sometimes  unique  specimens,  obtained  from  different  parts  of 
the  country. 

The  material  from  the  gynecological  operating  room  consisted  of  300  speci- 
mens, all  of  which  were  carefully  examined  both  macroscopically  and  micro- 
scopically. The  appendices  removed  in  the  surgical  operating  room,  more 
than  600  in  number,  were  all  submitted  to  careful  examination  of  the  gross 
specimen,  and  the  majority  were  sectioned  and  studied  histologically.  The 
specimens  obtained  at  autopsies  were  examined,  in  most  instances,  only  macro- 
scopically. 

A  classification  of  the  various  forms  of  inflammation  of  the  appendix  is 
somewhat  difficult,  for  there  is  no  definite  line  dividing  one  from  another.  The 
following  classification,  however,  dealing  first  with  the  change  occurring  in  the 
appendix  itself,  then  with  the  peritoneal  involvement,  and,  finally,  with  the 
various  widespread  complications,  seems  most  simple  from  a  pathological 
standpoint,  while  at  the  same  time  it  is  in  accordance  with  the  clinical  varieties. 

2G3 


264 


PATHOLOGY. 


Acute  Appendicitis. 
Subacute  and  chronic  appendicitis. 
Peritonitis. 

Metastatic  affections. 
Acute  appendicitis  may  be  further  divided  into  the  following  groups: 
(o)  Catarrhal. 

(b)  Diffuse. 

(c)  Purulent. 

(d)  Gangrenous. 

(e)  Perforative. 


JtS 


Ml  B 


03» 


ACUTE  CATARRHAL  APPENDICITIS. 

By  tins  is  meant  an  inflammatory  process  affecting  only  the  mucous  lining 
of  the  appendix  throughoul  the  attack,  and  not  involving  the  deeper  layers. 
In  all  cases  of  acute  appendicitis  there  is  probably  an  early  stage  in  which  t he  re- 
action is  limited  to  the  mucous  membrane,  but  in  the  majority  of  cases  this  is  only 
momentary,  and  so  speedily  gives  way  to  a  general  involvement  of  all  the  coats 

,  that  it  cannot  be  considered  as  a  well- 
defined  era  in  the  progress  of  the  at  lack, 
and  therefore  is  not  of  practical  impor- 
tance, according  to  our  present  knowl- 
edge. There  is,  however,  a  certain 
number  of  cases  in  which  a  mild  in- 
fection induces  definite  inflammatory 
changes  in  the  mucosa  alone,  although 
these  are  often  associated  with  a  con- 
gestion of  all  the  blood-vessels  supply- 
ing the  appendix.  Moreover  the  ap- 
pendix, when  it  has  once  been  the  seat 
of  a  diffu.se  inflammation,  may  readily 
be  excited  to  subsequent  acute  attacks 
in  which  the  active  process  is  sometimes 
limited  to  the  mucosa.  Macroscopically, 
in  acute  endo-appendicitis  the  appendix 
appears  slightly  thicker  than  normal, 
and  owing  to  a  more  or  less  general 
edema  it  may  be  somewhat  rigid.  The 
superficial  blood-vessels,  both  those  immediately  beneath  the  peritoneum  and 
those  between  the  subperitoneal  fibrous  layer  and  the  muscle,  are  prominent 
and  tortuous,  presenting  a  characteristic  arborescent  appearance.  There  is  not, 
however,  the  diffuse  redness  of  inflammatory  tissue,  nor  is  there  any  loss  of  the 
normal  sheen  of  the  serous  covering  (see  Fig.  3,  plate  I).     On  sectioning  the 


:?$  •Pot 


,«^rof  -  y^    Ll    „!'« 'trips'  .*>-! 


Fig.    157. — Section*   from   the   Specimen   Repre- 

b]  nii  d  in  Fig.  3,  Plate  I.     Aci  rs  Catarrhal 

Appem  dii  im-      Magnified  350  Times. 

The  section  shows  a  small  portion  •>(  the  BUrface 

pi  tit  helium  (n)  with  part  of  a  gland  on  t  he  right-hand 

Bide,  and  the  membrana   propria   (6)   containing  a 

dilated  capillary  (c).    The  epithelium  and  membrana 

propria  are  moderately  infiltrated  with  polyznorpho- 

nucleai  (rf). 


ACUTE    CATARRHAL    APPENDICITIS. 


265 


appendix  its  canal  is  found  to  be  patent,  and,  as  a  rule,  is  of  uniform  calibre.  It 
contains  a  little  muco-purulent  fluid.  The  mucosa  is  edematous,  diffusely  in- 
jected, and  granular  in  appearance.  The  tendency  to  a  hemorrhagic  infiltra- 
tion of  the  tissue,  common  to  all  forms  of  appendicitis,  is  not  wanting  in  the 
catarrhal  variety.  I  have  never  seen  distinct  ulceration  in  this  class  of  eases, 
and  am  inclined  to  believe  that  when  there  are  ulcerations  sufficiently  marked 
to  be  detected  with  the  naked  eye,  more  or  less  involvement  of  the  deeper  tis- 
sues will  usually  be  found. 

Histologically,  the   surface  epithelium,  which  is  generally  intact, 


a       mi 
- 


is 


.    •• 


! 


W9 


Fm        *  •»*    * 

,"-         c"    "iff   *  V, 


Fin.  158. — Deposit  of  Pigment  in  the  Mucosa.     Magnified  400  Times. 
a.  Normal  epithelium;  b,  glands;   c,  membrana  propria  infiltrated  with  a  few  red  blood  corpuscles  (d)  and 
containing  an  abundant  deposit  of  brown  granular  pigment,  partly  contained  within  cells.      (Gyll.  Path..  No. 
4871.) 


stains  rather  cloudily,  and  is  infiltrated  with  leucocytes  and  occasional  red  blood 
cells.  Slight  exfoliation  of  the  epithelium  is  frequently  found,  but  the  loss  is  soon 
repaired  by  cells  derived  from  the  surrounding  epithelium,  and  especially  from  the 
neighboring  glands.  The  gland  epithelium,  which  normally  multiplies  chiefly  by 
division  of  the  cells  lining  the  basal  portion,  shows  great  activity  near  the  sur- 
face as  well  as  deeper  down,  and  from  there  the  cells  which  repair  the  denuded 
surface  are  chiefly  derived.  The  increased  activity  of  the  gland  epithelium 
is  also  seen  in  the  abundant  mucous  secretion.  The  stroma  of  the  mucosa  is 
hvperemic,  edematous,  and  moderately  infiltrated  with  leucocytes  (Fig.   157). 


L'Citi  PATHOLOGY. 

The  lymph  nodes  arc  swollen,  the  genu  centres  prominent,  and  the  latter  often 
contain  a  very  large  number  of  dividing  nuclei.  The  endothelium  of  the  capil- 
laries and  the  reticular  cells  of  the  nodes  are  swollen,  and  degenerative  changes 
are  occasionally  present.  The  submucosa,  and  the  muscular  coats  of  the  appen- 
dix are  perfectly  normal,  and  its  peritoneal  covering,  apart  from  the  dilatation 

Of  its   blood-vessels,   is   unaltered. 

Simple  catarrhal  appendicitis  may  undergo  complete  repair,  and  in  cases 
which  presented  clinical  evidence  of  repeated  attack-,  the  appendix,  when 
removed  in  the  interval,  may  appear  quite  normal.  In  other  cases  the  pres- 
ence of  blood  pigment  in  the  mucous  membrane  is  the  only  evidence  of  a  former 
pathological  process  (see  Fig.  158);  or.  again,  the  interglandular  tissue  is  more 
fibrous  than  normal,  and  the  vessel  walls  appear  thickened. 

Kudo-appendicitis  is  a  predisposing  factor  in  the  formation  of  entero- 
liths in  the  appendix,  ami  a  frequent  cause  of  attacks  of  the  more  severe  forms 
of  appendicitis.    The  swelling  of  the  mucosa  tends  to  obstruct  the  lumen  at 

the  cecal  orifice,  causing  more  or  less  stasis  of  the  secretions  and  whatever  foreign 
material  may  lie  in  the  canal.  This,  as  will  lie  seen  later,  may  be  the  starting- 
point  in  the  formation  of  a  concretion,  and  it  also  favors  bacterial  activity. 


ACUTE  DIFFUSE  APPENDICITIS. 

In  the  majority  of  cases  of  appendicitis  which  give  rise  to  definite  symptoms, 
the  inflammatory  process  very  early  extends  beyond  the  mucosa,  ami  there  is  a 
general  involvement  of  all  the  coats.  In  the  gross  specimen,  the  difference  be- 
tween an  inflammation  limited  to  the  mucosa  and  the  diffuse  process  is  at  once 
evident.  In  diffuse  inflammation,  the  appendix  shows  a  notable  increase  in 
all  of  it-  dimensions,  and  instead  of  the  normal,  pale,  flaccid  organ,  of  about 
the  thickness  of  a  goose  quill,  it  may  lie  twice  the  usual  length,  and  is 
often  as  thick  as  the  index  finger,  the  tip  being  frequently  slightly  clubbed. 
The  appendix  is  tense  and  rigid,  and  exceedingly  hyperemic,  the  blood-vessels 
standing  out  in  high  relief  (see  Figs.  159  and  160).  Its  color  i^  a  diffuse  brighl 
red  or  dark  mahogany,  mottled  with  subperitoneal  extravasations  of  Mood  and 
often  presenting  lighl  yellowish,  or  greenish-yellow  areas  due  to  localized  foci 
of  suppuration  or  necrosis  i  Fig.  1.  Plate  III).  These  necrotic  areas  are  usually 
surrounded  with  a  deeply  injected  zone.  The  canal  contains  a  muco-purulent, 
or  purulent  exudate,  often  mingled  with  lilood.  The  mucosa  is  swollen,  in- 
tensely injected,  and  hemorrhagic;  its  surface  may  lie  smooth,  but  is  usually 
granular,  and  often  shows  irregular  folds  and  furrows,  or  hyperemic  wart-like 
excrescences  (see  Fig.  161).  Frequently  there  are  more  or  less  extensive  ero- 
sions. The  ulcers  may  he  small  and  punched-out  in  appearance  (Fig.  1.  Plate 
I),  but  more  commonly  they  have  ragged,  irregular  margins.    They  may  be 


ACUTE    DIFFUSE    APPENDICITIS. 


267 


single  or  multiple,  and  they  vary  from  slight  superficial  abrasions  to  extensive 
losses  of  tissue  comprising  a  large  portion  of  the  mucosa  and  involving  the  sub- 
mucosa  and  muscular  coats.  External  evidence  of  deep  ulceration  is  often 
seen  in  slightly  elevated,  dark  colored,  granular  areas  on  the  surface.  Erosions 
are  produced  in  various  ways:  by  the  mechanical  action  of  concretions  and 
foreign  bodies,  by  the  direct  action  of  septic  material  upon  the  surface  of  the 
mucosa,  by  the  necrosis  of  an  infected  lymph  follicle,  or  by  the  extension  into 
the  lumen  of  an  abscess  focus  originating  in  the  deeper  tissues.     In  the  speci- 


Fig.  lo9. — ArrTE  Appendicitis.  Serosa 
Deep  Mahogant  Color,  due  to  Hi  tf<  ir- 
rbagic  Infiltration.  Adhesions,  Pro- 
ducing Slight  Kink  near  the  Tip. 
(Gyn.  Path.,  No.  5606.) 


Tip 


epiploic'  appendages. 

Pig.  160. — Acutely  Inflamed 
Appendix, Showing*  !reatly 
Dilated  Blood-vessi  i  - 
Tip  Surrounded  with 
Light  Adhesions  (o).  (Spe- 
cimen from  T.  S.  Cullen.  i 


Fig.  161. — ArrTE  Ap- 
pendicitis.    The 
Inflammation 
Limited    to    the 
Distal    Half   of 
the  Appendix. 
The   contra 
tween  the  smooth  p:ile 
Dormal   mucous  mem- 
brane and   the 
ened,  hemi  n  i  hagic,  in- 
flamed portion  is  very 
striking. 


men  referred  to  above,  it  appears  as  if  the  multiple  punched- 
out  ulcers  had  resulted  from  the  breaking  down  of  a  large 
number  of  infected  lymph  follicles,  each  ulcer  being  in  the 
centre  of  a  system  of  Lieberkiihn's  crypts,  which  show  the 
characteristic  arrangement  of  these  structures  around  the  normal  lymph  nodes 
(see  "Structure  of  the  Appendix."  Chap.  VI).  Unfortunately  this  specimen 
was  lost  after  the  sketch  had  been  made,  so  that  it  could  not  he  studied  his- 
tologically. 

In  acute  appendicitis  ulcerations  are  almost  invariably  found  when  inspis- 
sated fecal  material  or  concretions  are  present  in  the  canal,  and  they  correspond 
in  position  to  the  location  of  the  concretion,  or  are  distal  to  it.     This  point  will 


268  PATHOLOGY. 

be  further  considered  in  discussing  the  pathogenesis  of  concretions  and  foreign 
bodies. 

Purulent  Appendicitis.  There  is  qo  sharp  dividing  line  between  puru- 
lent and  non-purulent  appendicitis,  and  at  anj  moment  a  non-purulent  process 
may  become  purulent.  The  nature  of  the  inflammatory  reaction  is  chiefly  due 
to  the  virulence  of  the  infection.  A  mild  infection  is  commonly  not  suppura- 
tive, while  a  severe  infection  induces  suppuration,  unless  the  virulence  of  the 
infective  material  is  so  great  that  a  fatal  toxemia  results  before  the  tissue  lias  had 
time  to  react.     In  such  cases  the  toxic  effects  are  so  overwhelming  that  after  the 

first  early  reaction  the  resistance  of  th 'ganism  is  paralyzed.     On  the  other 

hand,  if  there  is  profound  degeneration  of  the  tissues  depending  upon  some  me- 
chanical or  chemical  factor,  the  bacterial  invasion  may  result  in  gangrene  of  the 
part.  In  suppuration  there  is,  first,  necrosis  of  the  tissue  invaded,  and.  second, 
the  reaction  of  the  tissue  producing  cells  which  form  the  purulent  exudate.  To 
produce  this  second  phenomenon  a  certain  local  reactional  energy  is  necessarv, 

as  well  as  the  power  of  resistance  of  the  organism  as  a  whole.  It  maw  therefore, 
lie  said  with  every  reason  that  suppuration  is  an  evidence  of  the  ability  of  the 
tissues  to  offer  resistance  to  the  invasion  of  the  infective  agent.  Even  where 
necrosis  goes  on  and  gangrene  develops,  the  surrounding  tissue  still  tends  to 
react  by  eliminating  the  dead  part,  and  suppuration  ultimately  appears. 

One  of  the  chief  factors  promoting  suppuration  is  the  existence  of  some 
anterior  lesion  which  tends  to  obstruct  the  canal  of  the  appendix.  The  acute 
swelling  of  the  tissues  at  the  outset  of  an  attack  results  in  complete  closure  of 
the  stenosed  area,  and  in  consequence  there  is  a  damming  hack  of  the  inflamma- 
tory exudate.  The  defective  drainage,  associated  with  the  abnormal  condition 
of  the  tissue,  favors  the  development  and  exalts  the  virulence  of  the  micro- 
organisms, ami  finally  induces  suppuration.  The  increased  tension  as  the  appen- 
dix becomes  more  and  more  distended,  may  he  sufficient  to  overcome  the  ob- 
struction, or  if  the  tip  of  the  appendix  has  become  adherent  to  the  intestine  or 
some  other  hollow  viscus,  a  fistulous  opening  may  form  at  this  point.  In  either 
case  drainage  is  re-established  and  may  he  followed  by  resolution.  In  other 
instances,  the  purulent  exudate  i-  retained  within  the  appendix,  and  a  large 
pus  sac  results.  Besides  such  cases,  in  which  the  purulent  process  is  general, 
there  are  others  in  which  there  are  -mall  localized  foci  of  suppuration.  It  is 
not  uncommon  to  find  multiple  miliary  abscesses  in  acute  inflammation  of  the 
appendix.  These  may  originate  in  the  lymph  glands,  as  in  a  case  described 
by  Fenger,  or  in  any  of  the  tissues  of  the  appendix  wall.  They  are  probably 
due  to  the  direcl  action  of  the  bacteria  upon  the  tissue,  and  in  some  cases  col- 
lections of  bacteria  have  been  demonstrated  in  the  centres  of  these  areas.  These 
foci  of  suppuration  are  often  found  associated  with  erosions  on  the  surface  of  the 
mucosa.  In  the  fresh  specimen  they  appear  as  minute,  yellow,  or  greenish- 
yellow  areas,  which  are  in  sharp  contrast  with  the  surrounding,  intensely 
injected  tissue. 


GANGRENOUS   APPENDICITIS. 


I'll!) 


A  typical  case  is  seen  in  Fig.  1,  Plate  III.  The  specimen  was  removed  by 
T.  S.  Cullen,  eight  days  after  the  onset  of  an  attack  of  acute  appendicitis.  The 
appendix,  which  is  quite  free  from  adhesions,  is  swollen,  and  deeply  congested, 
while  at  two  points  abscess  foci  are  seen  immediately  beneath  the  serosa,  in 
imminent  danger  of  rupture.  A  longitudinal  section  of  the  same  specimen 
(Fig.  lf>2)  shows  complete  necrosis  of  the  mucous  membrane,  and  the  two 
abscess  foci  opening  into  the  canal.  A  fine  perforation  also  extends  to  the 
mesenteric  border. 

Gangrenous  Appendicitis. — This  condition  i<  essentially  characterized  by 
the  death  and  putrefaction  of  the  tissues,  and  is  due  to  the  action  of  microbes 


Fig.  162. — Acute  Appendicitis.  Appendix  lined 
with  Necrotic  Material.  Magnified  1.5 
Times. 

At  a  anci  «'  are  abscess  foci,  arid  at  a"  a  pin- 
hole perforation.  C  indicates  the  hypennici  edema- 
tous mesentery.  There  is  no  stricture  and  no  con- 
cretion. 


l'i',.  163. — Appendix  almost  Totally  Gangrenous 
ami  Surface  Partly  Covered  with  Large 
Plaques  ok  Greenish-yellow  Lymph.  No 
Evidence     of    Stricture    nor    Concretions. 

(Slug.  Path.,  No.  3232.) 


upon  tissue  which  has  been  subject  to  some  influence  inducing  partial  or  com- 
plete degeneration  (see  Fig.  163).  Gangrene  i-  related  to  suppuration  by  numer- 
ous transitions,  the  differentiation  being  sometimes  scarcely  definable.  While  it 
may  be  doubted  if  any  micro-organisms  can  affect  perfectly  healthy  tissue,  there 
are  some  which,  attacking  tissue  apparently  normal,  have  the  power  to  cause 
its  death  and  subsequent  putrefaction.  The  greater  number  of  organisms. 
however,  can  only  act  upon  tissue  which  is  profoundly  altered.  The  most  im- 
portant factors  inducing  gangrene  are  those  which  act  by  obstructing  the  circu- 
lation, and  so  producing  a  local  ischemia.     The  interruption  t<>  the  blood  current 


270  PATHOLOGY. 

may  occur  in  one  of  the  small  arteries  which  supplies  only  a  limited  portion  of 
the  appendix;  or  the  main  artery  may  be  involved  ;  or,  in  some  instances,  l»itli 
the  vein  and  artery,  in  which  case  the  entire  appendix  becomes  gangrenous. 
It  is  not  uncommon  to  find  the  appendix  represented  by  a  dark  greenish-black 

mass,  which  has  separated  from  its  cecal  attachment  and  lies  free  in  the  ab- 
dominal cavity.  The  obstruction  to  the  circulation  may  be  caused  by  thrombo- 
angeitis,  twists,  angulations,  and  compression  by  adhesions,  or  by  a  hernial  ring. 
Localized  areas  of  gangrene  may  also  be  produced  by  the  pressure  of  concre- 
tions. Mechanical  factors  may,  in  themselves,  be  sufficient  to  cause  complete 
obstruction,  as,  for  instance,  when  the  appendix  becomes  strangulated  by  means 
of  adhesions,  etc.  More  commonly,  however,  a  partial  obstruction  occasioned 
by  them,  is  rendered  complete  by  sudden  swelling  of  the  appendix,  taking  place 
at  the  outset  of  an  acute  inflammatory  attack.  It  is  only  ill  this  way  that  a 
concretion  is  able  to  produce  gangrene  of  the  portion  of  the  wall  with  which  it  is 
in  contact.  The  pressure  of  the  concretion,  added  to  the  acute  edema  which 
accompanies  the  early  inflammatory  changes,  compresses  the  small  vessels,  and 
produces  local  ischemia  with  subsequent  gangrene. 

When  gangrene  is  the  result  of  interference  with  the  circulation  by  means 
of  strictures,  twists,  or  adhesions,  the  entire  appendix,  or  the  portion  beyond 
the  obstruction,  is  involved;  and,  as  mentioned  above,  a  similar  result  follows 
thrombosis  of  the  main  blood-vessels.  Thrombo-arteritis  affecting  one  of  the 
branches  may  he  followed  by  a  localized  area  of  necrosis,  notwithstanding  the 
rich  arterial  plexus  in  the  submucosa,  as  it  has  been  found  thai  the  intestinal 
vessels  are  unable  to  compensate  circulatory  obstruction  of  a  degree  readily 
compensated  in  other  areas.      Most  frequently,  the  tip  of  the  appendix  is  affected 

(see  Figs.  1  ami  2,  Plate  II),  bul  it  is  not  unusual  to  find  several  distinct  areas  of 
gangrene  both  in  the  proximal  and  the  distal  portions  of  the  appendix.  Such 
a  case  is  shown  in  Fig.  3.  Plate  II,  where  the  surface  of  the  appendix  is  mottled 
bright  red  and  green,  and  at  no  point,  from  the  base  to  the  tip,  is  the  entire 
circumference  free  from  gangrene.  In  some  instances,  only  the  proximal  end 
becomes  gangrenous,  in  which  case  the  necrosis  may  be  determined  by  the  pres- 
ence of  a  concretion;  or,  the  gangrene  may  be  of  the  annular  variety,  and  probably 
due  to  thrombosis  of  the  separate  arterial  branch  which  sometimes  supplies  this 
region.  In  such  a  case  there  may  be  a  complete  separation  of  the  fairly  normal 
appendix  from  its  cecal  attachment.  Tn  other  cases,  again,  the  outer  coats  may 
entirely  slough  off.  leaving  an  intact  mucous  membrane.  Such  a  case  is  described 
by  Fowler.  The  role  of  bacteria  in  the  production  of  tissue  necrosis  is  an  impor- 
tant one,  and  in  cases  where  gangrene  of  the  appendix  is  partly  due  to  mechanical 
influences,  the  heightened  virulence  of  the  contained  bacteria,  in  the  presence 
of  the  lessened  vitality  of  the  tissue,  undoubtedly  promotes  the  destructive 
process.  The  action  of  bacterial  poison  may  cause  gangrene  even  in  the  absence 
of  obstruction  to  the  circulation,  the  degenerative  process  being  then  most 
pronounced  in  the  interior,  where  the  infective  substance  is  in  direct  contact 


mnl'iil    [><nnIo' 


.11  3TAJ1  ^O  HOITl! 

'    I,:  i   ■:.'         il 
irnofl   I  >•  n  ■ 

1  ■ 
.noifto 


DESCRIPTION  OF  PLATE  II. 

Fig.  1. — Acute  appendicitis,  thirty-six  hours.  The  appendix  slightly  enlarged,  tense  and 
injected.  At  the  tip  a  small  gangrenous  area  surrounded  l>y  a  dark  colored  hemorrhagic  area. 
No  adhesions.     (G.  P.  Muller,  derm.  Hosp.,  Phila.) 

Fig.  2. — Acute  appendicitis.  The  appendix  swollen  and  congested.  The  gangrenous  dis- 
tal third  bent  at  an  obtuse  angle  by  a  band  of  adhesions.      (H.  A.  Kelly.) 

Fig.  3. — Gangrenous  appendicitis,  forty-eight  hours.  The  appendix  greatly  enlarged,  total 
gangrene  of  the  distal  third,  and  irregular  areas  of  gangrene  in  proximal  portion.  Near  the  mid- 
dle the  canal  is  distended  with  a  round,  hard  concretion.  Masses  of  fibrin  and  a  few  old  adhe- 
sions on  the  surface.     (W.  S.  Halsted.) 


Horn  and  Beck--. 


GANGRENOUS   APPENDICITIS. 


271 


with  the  tissues.  It  is  particularly  the  putrefactive  organisms  contained  in 
decomposing  feral  material  which  produce  this  condition.  An  excellent  ex- 
ample is  seen  in  the  case  illustrated  in  Fig.  164.  Here  the  mucosa,  as  a  whole, 
is  gangrenous,  but  apart  from  the  perforation  at  the  tip  the  gangrenous  process 
has  not  involved  the  deeper  layers,  which  show  an  intense,  purulent,  inflamma- 
tory reaction. 

The  mesappendix  in  acute  inflammation  becomes  greatly  thickened,  owing 
to  the  dilatation  of  the  blood- vessels,  and  the  infiltration  of  the  lax  areolar 
tissue  with  a  serous  and  cellular  exudate.     The  tissue  also  becomes  exceedingly 


.S 


Fig.  164. — Total  Gangrene  of  the  Interior  of 
the  Appendix  Associated  with  the  Pres- 
ence of  Fecal  Masses.  (Specimen  prom 
J.  M.  T.  Finney.) 


Fig.   165. — Acute    Appendicitis  with    Thickened 
Hemorrhagic  Mesappendix. 
The    distal    two-thirds   of    tin  .    (a)    is 

hemorrhagic,  and  also  the  small   masse     ol    tat    (6). 
Adhesions  are  found  at  c.    (Gyn.  Path.,  No.  0252.) 


friable,  so  that  the  ligature,  although  placed  with  the  utmost  care,  often  tears 
directly  through  it.  The  color  is  usually  reddish,  often  a  dark  red.  from  the 
presence  of  hemorrhage  (see  Fig.  165).  In  the  presence  of  old  adhesions  or 
twists  it  is  evident  that  the  acute  edema  of  the  mesappendix  could  readily  induce 
partial  or  complete  occlusion  of  the  large  blood-vessels;  also,  in  the  case  of 
advanced  arterio-sclerosis  of  the  main  blood-vessel,  the  circulation  may  be 
greatly  impeded,  ami  even  completely  obstructed  by  the  pressure  of  the  in- 
filtrated tissue. 

Histology  of   Acute   Diffuse   Appendictis. — The  whole  appen- 


9T2 


PATHOLOG1  . 


dix  shows  a  greater  or  less  degree  of  inflammatory  reaction.  At  the  outset,  there 
is  a  general  congestion  and  edema,  especially  affecting  the  mucous,  submucous, 
and  peril a]  layers.  The  mucosa  shows,  usually,  some  degeneration  of  the  sur- 
face epithelium,  and,  as  a  rule,  of  the  gland  epithelium.  In  some  instances  these 
changes  are  insignificant,  consisting  in  a  slighl  swelling  and  cloudiness  of  the 
cells;  while  in  others  a  large  portion  of  the  epithelium  is  destroyed.  This  is 
sometimes  due  to  effusion  of  blood,  which,  lifting  up  the  epithelium  from  the 
underlying  tissue,  deprives  it  of  its  nutriment:  leucocytes,  chiefly  polymorpho- 
nuclear, are  found  in  variable  numbers  throughout  the  epithelium  and  in  the 
exudate  upon  the  surface.    The  glands,  besides  showing  degenerative  changes 

in    the    epithelium,    are 
I 


0;C 


o 


- 


:/■: 


•; '  :"\- ' 


■ 
a 


l. 


greatly  compressed,  and 
sometimes  destroyed  by 
the    acute     swelling    of 
the     interstitial     tissue. 
»*'    '"'"'     changes     in     the 
lymph  nodes    are   often 
|»B    marked,  the  blood   cap 
J  illaries     are     congested, 

and  the  endothelial  ele- 
ments swollen  and  pro- 
liferating; leucocytes 
are  present  in  variable 
■  • .  numbers,  and  there  are 
,  often  large  phagocytes 
containing  cellular  de- 
tritus, usually  fragments 
of  leucocytes;  occasion- 
all  v  the    centre    of   the 


Fio.   100. — Acute  Diffuse  Appendicitis.     Magnified  40  Times. 
\n  erosion   Co-6)  in  the  crevice  between  two  folds  of  mucous  mem- 
brane.    The  mucosa  on  either  side  of  the  ulcei  i    edematous  and  infiltrated,       follicle     is     degenerated 
i!     urface  being  bathed  with  a  purulent  exudate.   At  the  base  of  the  mucosa 
there  is  a  small  abscess  focus  (d);  c  indicates  a  lymph  follicle.     (Specimen       and    it     may    even    open 

fr L  M  llek""'n)  upon  the  surface  of  the 

mucous  membrane.  The 
interglandular  tissue,  as  a  rule,  shows  the  most  marked  changes.  It  is  greatly 
congested,  and  permeated  with  a  serous  effusion,  extravasated  blood,  and  a 
more  or  less  abundant  cellular  exudate.  Polymorpho-nuclear  cells  usually  pre- 
dominate, but  there  is  also  an  increase  in  the  number  of  small  round  and 
plasma  cells.  In  some  instances,  eosinophiles  make  up  a  large  proportion  of  the 
infiltrating  cells.  Abrasions  ami  ulcerations  are  usually  found,  under  the 
microscope,  where  the  inflammation  is  at  all  severe,  although  they  may  not  be 
apparent  to  the  naked  eye.  They  occur  most  frequently  in  the  depressions 
between  the  mucous  folds,  the  point  where  the  lymph  nodes  commonly  reach 
the  surf  ace  (Figs.  166  and  l(i7).     The  surface  of  the  erosion  is  covered  with 


HISTOLOGY    OF    ACUTE    APPENDICITIS. 


273 


mucus  and  fibrin  intermingled  with  cellular  detritus;  underneath  there  is  the 
usual  acute  granulation  tissue.  In  the  periphery  of  the  eroded  area  there  are 
often  areas  of  canalized  fibrin,  and  vascular  changes  are  observable  extending 
some  distance  away.  Purely  leucocytic,  fibrinous,  or  hyaline  thrombi,  partially 
or  completely  filling  the  lumen  of  the  vessel,  are  frequently  seen,  and  may  be 
found  in  one  or  more  of  the  capillaries  or  small  vessels  in  most  cases  of  acute 
appendicitis,  more  especially  in  the  vicinity  of  erosions.  Thrombi,  showing  the 
characteristic  arrangement  of  fibrin  and  granular  material  and  containing  a 
variable  number  of  cellular  elements,  are  also  seen,  particularly  in  the  larger 
vessels  of  the  subserous  tissue. 

Purulent    t  h  r  ombo-arteritis   and   thro  m  bo-  p  hlebitis 
occur  in  some  cases. 


The  vessels  most  fre- 
quently affected  are 
those  of  the  subniu- 
cosa  in  the  region  of 
an  erosion,  or  the 
comparatively  large 
vessels  coursing  be- 
tween the  external 
muscular  coat  and 
the  peritoneum.  In 
exceptional  instances 
there  are  acute 
changes,  acute  ange- 
itis  or  thrombo-ange- 
itis,  in  the  large  ves- 
sels contained  in  the 
mesappcndix.  Where 
total  gangrene  of  the 
appendix  takes  place 
without  any  external 
constriction     of     the 


-,d 


*.*»  ^  *£  *e 


« 


»e 


'4*  «**£ 


»  3^rf.e- 


-«?*  ^ 


Flo.  lb". — Higher  magnification  of  the  margin  of  the  ulcer  seen  in  the 
preceding  figure.  The  epithelium  at  a  is  normal;  at  6  the  cells  are  swollen 
and  cloudy,  and  from  here  to  the  edge  of  the  ulcer  the  epithelium  shows  more 
pronounced  degenerative  changes  and  is  infiltrated  with  leucocytes  (c).  The 
surface  of  the  ulcer  (rf )  consists  of  a  mass  of  fibrous  leucocytes  and  red  blood 
cells.  More  deeply  the  tissue  is  composed  of  connective  tissue,  with  abundant 
large  oval  and  fusiform  cells,  dilated  capillaries,  and  a  diffuse  infiltration  of 
VAgSQls    |t   maV  be  as-       leucocytes  and  red  blood  cells.     Magnified  400  times. 

sumed   that    in    the 

majority  of  instances  thrombosis  of  one  or  more  of  the  large  vessels  has 
occurred.  It  is  difficult,  however,  to  demonstrate  such  a  condition  in  spec- 
imens removed  at  operation,  as,  owing  to  the  use  of  the  cautery  or  the  ligature, 
or  from  the  effect  of  clamps,  this  portion  of  the  specimen  is  usually  unsatisfactory 
for  careful  study.  At  autopsy,  however,  it  is  not  rare  to  find  thrombosis  and 
purulent  thrombo-phlebitis  involving  the  appendical  vessels  and  their  tributaries, 
and  such  cases  have  also  been  demonstrated  at  operation.  The  lymph  channels 
of  the  appendix  and  its  mesentery  in  acute  inflammation  are  often  found  greatly 
is 


274 


I'vriioi.ocY. 


distended  with  lymph  corpuscles,  and  various  grades  of  lymphangitis  may  be 
observable. 

A  case  of  unusual  interest  in  respect  to  the  condition  of  the  Lymphatics  has 
boon  given  me  by  T.  S.  Cullen,  who  removed  the  appendix  from  a  child  eight 
years  old  on  the  fourth  day  of  a  rather  mild  attack  of  appendicitis.  Recovery 
was  uneventful,  except  for  an  attack  of  acute  tonsillitis,  which  developed  on  the 
fourteenth  day.    The  appendix  was  hyperemic  and  somewhal  tense.    There  was 

a  slight,  viscid,  fibrinous  exudation  upon  the  surface,  but  no  adhesions  ami  no 
evidence  of  peril  unit  is.  Microscopic  exaiuinat  ion  showed  a  diffuse  acute  inflam- 
mation without  evident  ulceration.  The  chief  interesl  in  the  specimen  centres 
in  the  acute  lymphangitis.  In  all  parte  of  the  appendix,  but  especially  in  the 
serous  coat  and  in  the  mesentery,  the  lymphatics  are  engorged  with  cells,  mostly 


- 


£& 


Fig. 


168. — Acute    Appendicitis,    with    Severe    Lymphangitis.      A    Section    Showing    the    Peritoneal 

Cum     am.    RIeSENTERT.        MAGNIFIED    32    TIMES. 

On  The  right-hand  side  <»f  the  figure  the  peritoneum  (a)  is  thickened  and  densely  infiltrated.  On  the  left 
side  the  inflammatory  reaction  i  !»■  intense,  and  :ii  '>  tin-  edge  of  the  external  mu  culai  coal  i  seen.  The 
mesappendu  i  everywhere  denserj  infiltrated  and  tin-  lymphatics  [c)  in  the  mesenten  and  in  the  appendix  wall 
are  con  spicuou  I  \  distended. 


lymphocytes,  although  abundant  polymorpho-nuclear  leucocytes  are  sometimes 
present,  and  the  vessel  walls  are  infiltrated  with  leucocyte-  (see  Fig.  168).  At 
several  points  organizing  thrombi  are  found  (see  Fig.  169).  Two  or  three  of  these 
occupy  the  large  lymph  sinuses  in  the  periphery  of  the  solitary  follicles.  They 
are  formed  of  large,  oval,  endotheloid  cells,  an  abundant  intercellular  substance, 
and  leucocytes. 

The  submucosa  in  acute  diffuse  appendicitis  usually  shows  a  severe  grade 
of  inflammation.  The  blood-vessels  are  engorged,  the  tissue  is  highly  edem- 
atous, and  there  is  a  general  cellular  infiltration  consisting  of  polymorpho- 
nuclear, small  round,  and  plasma  cells.  The  connective  tissue  cells  are  swollen 
and  actively  proliferating.  When  ulceration  occurs,  the  submucosa  is  almost 
invariably  involved.     Miliary  abscesses  originating  in  lymph  nodes,  as  a  rule, 


HISTOLOGY    OF   ACUTE    APPENDICITIS. 


_'/.) 


involve   this   layer,   and   very   often    abscess  foci  develop  primarily    in    this 
region. 

The  circular  and  longitudinal  muscular  coats  share  to  a  variable  extent 
in  the  inflammatory  reaction.  In  many  instances,  the  only  evidence  of  reaction 
is  found  along  the  course  of  the  blood  and  lymph  vessels  in  the  hiatuses  of  the 
musculature.  There  is  usually  considerable  leucocytic  infiltration  of  these 
areas,  and  connective  tissue  proliferation.  A  purulent  inflammation  confined 
to  the  mucous  and  submucous  layers  may  extend  outward  by  way  of  these 
structures,  and  cause  an  acute  peritoneal 
reaction,  or  even  a  perforation,  without 
involvement  of  the  musculature.  How- 
ever, as  a  rule,  in  suppurative  appendi- 
citis there  is  also  more  or  less  infiltration 
along  the  course  of  the  vessels  which  run 
parallel  to  the  muscle  bundles,  and  in  some 
instances  rows  of  leucocytes  separate  the 
individual  muscle  fibres.  The  interstitial 
tissue  of  the  muscular  coat 
and  the  connective  tissue  celh 
and  proliferating;  the  muscle 
other  hand,  show  more  or 
degenerative  changes. 

The  peritoneum  and  the  subperitoneal 
fibrous  tissue  undergo  important  changes. 
Often  while  the  musculature,  and  even 
the  submucosa,  shows  no  perceptible 
change,  a  marked  inflammatory  reaction 
is  found  in  the  serous  membrane.  At  the 
outset  of  the  attack  there  is  extreme  con- 
gest ion  of  the  blood-vessels,  which  is  almost 
immediately  accompanied  with  an  intense 
edema.  Soon  there  is  an  abundant  leuco- 
cytic infiltration,  and  a  high  degree  of 
connective  tissue  proliferation.  Vascular 
changes,   as  noted   above,   are  frequently 

observable  in  this  region.     Interstitial  hemorrhages  usually  occur  and  are  often 
very  extensive. 

The  changes  in  the  mesappendix  consist  chiefly  in  edema  and  dilatation  ot 
blood-vessels.  There  is  usually  a  slight  leucocytic  infiltration  surrounding  the 
blood-vessels  and  extravasations  of  blood  are  commonly  met  with.  In  some 
instances  there  is  a  general  purulent  infiltration  of  the  adipose  tissue,  and  nec- 
rosis of  part  or  the  whole  of  the  mesentery  is  not  rare.  The  changes  in  the 
blood-vessels  and  lymphatics  of  the  mesappendix  have  already  been  described. 


••«•  six  -  t  *&&  \£  \    ^ 

-  *wV»  •  "  .  ■"Qi£k<ter 


1   "V   qj*^, 


Fig.  169.- 


Mag- 


■Thrombus  in'  a  Lymph  Sinus, 
nified  225  Times. 
a  marks  the  Lymph  sinus,  which  contains  a 
few  lymphocytes  (c)   :l1"'  'S  distended  with  the 
thrombus  (6). 


276 


PATIK  )!.<>(  iV. 


Perforative  Appendicitis.  Perforation  may  take  place  in  any  variety  of 
acute  appendicitis,  and  in  any  stage  of  the  attack.  In  some  instances  the  first 
symptoms  are  due  to  the  occurrence  of  perforation,  while  in  other  cases  the  acute 
attack  lias  apparently  subsided  when  perforation  suddenly  takes  place.  The  rup- 
ture may  be  of  pin-hole  size  or  there  may  be  a  wide  ragged  aperture  through  which 
a  large  concretion  can  escape.  In  the  appendix  represented  in  Fig.  170,  almost 
the  entire  circumference  is  involved  in  the  large  perforation  which  occupies  the 


centre  of  a  gangrenous  area  surrounded  by  a  zone  of  intense 


Hyperemia. 


This 


appendix  was  removed  by  T.  S.  CuLLEN  thirty-six  hours  after  the  onset  of  the 
attack.  There  may  also  be  two  or  more  perforations.  Very  often,  in  the  labora- 
tory, unsuspected  perforations  are  detected,  which  have  been  sealed  by  adhe- 
sions, most  frequently  by  the  adherent  omentum.  The  fac- 
tors concerned  in  the  production  of  a  rupture  are  various; 
it  may  follow  the  extension  of  an  erosion  to  the  peritoneal 
surface,  the  degeneration  of  the  tissue  in  the  vicinity  of  an 
abscess  focus,  or  it  may  be  the  result  of  circumscribed  or 
general  gangrene.  A  tensely  distended  empyema  often  ter- 
minates in  rupture  of  the  appendix  walls,  and  it  is  particu- 
larly in  such  cases,  where  a  large  amount  of  highly  virulent 
material  is  emptied  into  the  abdominal  cavity  that  the 
most  fatal  forms  of  peritonitis  result.  Pin-hole  perforations 
mayresull  from  the  continuance  of  a  purulent  process  along 
a  muscular  hiatus.  An  appendix  apparently  affected  merely 
li\  a  slight  non-suppurative  inflammation  may,  neverthe- 
less, show  a  fine  perforation  corresponding  to  the  position 
of  an  hiatus.  A  good  example  of  this  form  of  perforation 
is  seen  in  Fig.  332,  p.  621. 

T  h  e  m  o  s  t  i  m  port  a  n  t  cause  o  f  r  u  p  t  u  r  e 
is  the  necrosis  of  the  tissue,  induced  by  the 
presence  of  concretions,  the  pressure  effect  of  which  is 
brought  into  play  by  the  swelling  of  the  tissue  in  acute 
inflammation.  The  association  of  concre- 
tions with  perforative  appendicitis  is  so  often  observed  that  an  etiological 
relationship  cannot  he  questioned,  and  in  many  cases  the  evidence  of  cause  and 
effect  may  he  clearly  demonstrated.  In  some  instances  a  small  rupture  is 
found  directly  over  the  most  prominent  portion  of  the  concretion  (see  Fig. 
235),  in  others  an  impending  rupture  is  found  in  a  corresponding  area.  The 
direct  agency  of  pointed  and  irregular  f  o r  e  i g n 
1)  o  d  i  e  s  in  c  a  u  s  i  n  g  a  per  f  o  rati  o  n  o  f  the  a  p  p  e  nd  i  X 
will  he  considered  in  another  section. 

Where  rupture  follows  an  erosion  the  procedure  is  gradual,  the  various  layers 
giving  way  as  the  degenerative  process  extends  outward.  In  the  case  of  gan- 
grene, rupture  of  the  different   coats  is  probably  in  most  instances  practically 


Pig.  170. — Perforative 
a  1'  pehdic]  ii  8. 
(Specimen  from 
t.  s.  collen.) 


PERFORATIVE    APPENDICITIS. 


!77 


simultaneous.  In  some  specimens  the  inner  coats  have  given  way,  only  the 
peritoneal  covering  remaining.  In  the  appendix  shown  in  Fig.  171,  operation 
thirty-six  hours  after  the  onset,  an  extensive  clean-cut  perforation  of  all  the 
outer  layers  has  occurred,  leaving  only  a  pouch  of  mucous  membrane  which, 
although  gangrenous,  has  not  ruptured.  The  favorite  location  of  the  perfora- 
tion is  at  or  near  the  tip  of  the  appendix,  but  it  is  not  uncommon  to  find  a  per- 
foration directly  at  the  base,  or  at  some  intermediate  point.  A  perforation 
at  the  base  may  involve  the  neighboring  portion  of  the  cecum  and  produce  a 
wide  opening  through  which  the  intestinal  con- 
tents escape.  The  extension  by  continuity  of  the 
inflammatory  disease  of  the  appendix  to  the  sur- 
rounding portion  of  the  cecum  has  occasionally 
resulted  in  a  perforating  ulcer  of  the  cecum.  The 
propagation  of  the  disease  to  the  cecum  may  be 
owing  to  thrombo-phlebitis  or  to  the  direct  action 
of  bacteria  upon  the  diseased  tissues.  Such 
cases  m a y  be  wrongly  interpreted 
as  instances  of  primary  disease 
of  the  cecum.  As  explained  before,  a  per- 
foration of  t  he  proximal  end  of  the  appendix  may 
result  in  its  complete  separation  from  the  cecum. 
It  has  then  been  found  Moating  free  in  an  abscess 
cavity,  or  has  become  attached  to  some  other 
structure,  receiving  nutriment  through  newly 
formed  vessels  by  means  of  adhesions.  In  a  case 
of  G.  W.  Crile's  (personal  communication),  oper- 
ated on  after  several  attacks  of  appendicitis,  the 
distal  3  cm.  of  the  appendix  was  found  closely 
adherent  to  the  surrounding  structures,  9  cm. 
from  the  normal  point  of  attachment.     The  proxi- 


mal end  of  the  fragment  was  well  rounded  off,  and 


Fig.  171. — Acute  Appendicitis. 
The  distal  two-thirds  distended 
and  intensely  injected.  On  the  ante- 
rior surface  a  gangrenous  pouch  of 
mucous  membrane,  covering  a  concre- 
tion, protrudes  through  a  rupture  in 
the  outer  Layers.  A  similar  protru- 
sion of  mucous  membrane  is  seen  on 
the  convex  margin.  There  are  three 
concretions  in  the  appendix.  (Surg. 
Path..  No.  :ji7.;.i 


completely  closed.  The  lumen  contained  a  small 
amount  of  fluid.  Similar  cases  have  been  de- 
scribed by  R.  Morris,  Barth  and  others.  Acute 
appendicitis  may  undergo  repair,  hut  a  complete 
restitutio  ad  integrum  is  probably  exceedingly  rare. 

As  a  rule,  various  deformities  remain,  such  as  angulations,  twists,  and,  what 
are  perhaps  most  important,  irregularities  in  the  canal,  consisting  of  scars  ami 
strictures  (see  residual  conditions).  The  vascular  changes  which  Fowler  be- 
lieves to  be  so  important  I  have  not  found  to  he  often  present,  at  any  rate  in 
the  larger  vessels.  Obliterative  arteritis  is,  however,  common  in 
the  submucosa,  and  in  some  instances  obliterative  t  hro  m  bo- 
ar terit  is   is   found   in    the  large  vessels  of   the  peritoneum  anil  muscular 


27S  PATHOLOGY. 

hiatuses,  and  may  even  involve  the  main  appendical  vessel.  This  point  will 
be  further  considered  in  connection  with  other  residual  conditions  following 
acute  and  chronic  affections. 

Chronic  Appendicitis. 

In  this  group  are  included  subacute  and  chronic  inflammatory  conditions 
of  the  appendix,  and  also  that  varied  class  of  cases  which  I  have  designated 
residual  appendicitis,  in  which  the  essential  lesions  are  the  effects 
of  an  anterior  inflammation  rather  than  an  active  process. 

Very  often,  alter  an  attack  of  acute  appendicitis,  it  may  be  after  the  first, 
or  after  several  preceding  attacks,  changes  remain  which,  under  the  continued 
influence  of  an  infective  agent  lead  to  a  chronic  condition.  Hut  chronic  appen- 
dicitis is  not  necessarily  preceded  by  an  acute  process.  It  may  have  an  in- 
sidious onset  and  occur  independently  of  any  acute  attack.  Very  many  cases 
are  discovered  accidentally  in  the  course  of  operations  undertaken  for  the  relief 
of  other  abdominal  affections  in  patients  who  have  never  suffered  from  any 
symptoms  referable  to  the  disease.  Moreover,  from  the  pathological  findings 
of  many  specimen-  removed  in  what  was  supposed  to  he  a  firsl  attack  of  appen- 
dicitis, it  would  appear  that  very  often  acute  appendicitis  i-  preceded  by  a  prim- 
ary chronic  inflammation.  In  fact,  some  writers  express  the  opinion  that  acute 
appendicitis  never  arises  de  novo,  but  is  always  dependent  upon  the  deleterious 
effect  of  an  anterior  chronic  process,  excepting,  of  course,  such  cases  a-  are  the 
direct  result  of  injury  by  foreign  bodies,  strangulation  in  a  hernial  ring,  etc 
RlEDEL  believes  that  acute  appendicitis  has  always  an  insidious  onset,  one  of 
the  mosl  important  predisposing  causes  being  a  chronic  primary  disease,  "  appen- 
dicitis granulosa."  Chronic  inflammation  of  the  appendix  i-  essentially  a  hyper- 
trophic process  and  produces  a  characteristic  thickening  and  rigidity  of  its  walls. 
In  rare  instance-  | he  inflammatory  reaction  seems  to  lie  confined  to  the  mucous 
membrane,  but,  as  a  rule,  all  the  coats  are  similarly  affected.  Macroscopically 
the  appendix  is  found  to  he  thicker  than  normal,  hut  may  he  either  increased 
or  diminished  in  length.  It  is  quite  common  to  find  the  appendix  very  thick 
and  short,  often  not  more  than  three  or  four  centimetres  long  and  a  centimetre 
or  more  in  diameter.  In  a  case  reported  by  Weir,'  the  densely  adherent  in- 
flamed appendix  was  only  half  an  inch  long,  and  nearly  half  an  inch  thick. 
There  had  been  several  sharp  attacks  of  inflammation,  and  after  removal  of  the 
appendix  recovery  was  prompt  and  permanent.  In  some  instances  there  i-  a 
moderate  increase  in  length. 

The  whole  organ  may  he  uniformly  thickened  to  the  size  of  the  little  finger 
or  larger ;  very  often  it  i-  club-shaped,  the  proximal  end  being  almost  normal  or 

ii  reduced  in  thickness,  while  the  tip  is  enlarged.  In  other  instances,  the 
outer  half  or  more  is  hypertrophied,  while  again  there  may  be  irregular  thicken- 
ing- separated  by  normal  or  constricted  portion-. 

The  mesappendix  maybe  unaltered,  hut  it  i<  often  thickened  and  indurated, 


CHRONIC    APPENDICITIS. 


279 


and  is  apt  to  be  more  or  less  shortened.  The  color  of  the  appendix  is  usually 
reddish,  and  the  superficial  blood-vessels  are  very  tortuous  and  prominent, 
while  ecchymotic  areas  are  not  uncommon  (see  Fig.  2.  Plate  I).  There  are  also 
often  characteristic  anemic  areas,  usually  at  the  tip.  significant  of  an  oblitera- 
tive  process.  This  is  well  shown  in  Fig.  172,  where  the  whitish  knob-like  tip 
is  sharply  contrasted  with  the  brightly  injected  median  portion. 

The  most  striking  feature  in  chronic  a  p  pendicitis 
is  the  a  p  p  e  ar  an  e  e  of  e  x  t  r  e  m  e  r  i  g  i  d  i  t  y.  The  appendix  may 
project  directly  out  from  the  cecum,  independently  of  adhesions  or  any  other 
external  influence,  the  mesentery  being  often  tightly  stretched.  Again,  with  a 
greatly  shortened  mesentery,  the  appendix  maybe  sharply  bent  upon  itself,  or 
it  may  project  in  the  form  of  a  spiral.  Fig.  148,  No.  in.  p.  200.  presents  a  good 
example  of  a  triple  kink 
due  to  adhesions  surround- 
ing an  unusually  long 
appendix  with  a  corre- 
spondingly short  mesen- 
tery, the  tissues  hav- 
ing become  rigid  as  a 
result  of  inflammation. 
The  characteristic  rigidity 
is  particularly  evident  to 
the  touch.  Upon  rolling 
the  appendix  between  the 
fingers  and  compressing 
it,  instead  of  the  normal, 
easily  collapsible  walls, 
there  is  found  a  dense  un- 
yielding tube,  the  sides  of 
which  cannot  be  pressed 
together.  Sometimes  the 
thickened    appendix    may 

be  readily  palpated  through  the  abdominal  wall  and  rolled  under  the  fingers. 
Section  shows  a  general  thickening  of  the  tissues,  but  more  especially  of  the 
submucous  and  serous  membranes.  The  lumen,  instead  of  assuming  the 
stellate  form  of  the  normal  appendical  canal,  retains  a  circular  outline,  and, 
except  in  strictured  areas,  remains  widely  open;  a  condition  which,  associated 
with  enfeebled  muscular  power,  favors  the  reception  and  retention  of  foreign 
material.  The  canal  also  presents  various  irregularities  produced  by  tin1 
cicatrization  of  ulcers  or  hypertrophy  of  the  walls.  If  the  hypertrophy  or 
constriction  of  the  appendix  walls  results  in  complete  occlusion  of  the  canal 
at  one  point  while  the  remainder  is  still  patulous,  or  if  a  partial  stenosis  is 
rendered  complete  by  means  of  kinks  or  twists,  the  part  beyond  the  obstruc- 


stricf. 


I 


' 


Fig.   172. — Chronic  Appendicitis  with    Anemic  Bulbous  Tip  Con- 
taining a  Soft  Fecal  Mass.      (Gyn.  Path.,  No.  5640.) 


_'S.I 


PATHOLOGY. 


t ion  may  become  distended  with  a  clear  mucous  or  serous  fluid,  or  with  a 
turbid  purulent  exudate  producing  a  hydro-  or  pyo-appendix.    The  mucosa 

is  usually  thickened,  bul  in  some  instances  appears  to  lie  thinner  than 
normal  and  may  even  he  indistinguishable  from  the  underlying  submucous 
tissue.     Its  surface  may  he  smooth,  sometimes  having  a  glazed  appearance,  or 

it  may  he  granular,  or  wart-like.  In  exceptional  instances  mucous  polypi  de- 
velop as  shown  in  Fig.  173  (also  see  Chap.  XXXI).  The  color  of  the  mucosa  is  a 
bright  red,  usually  mottled  with  petechial  hemorrhages.  A  characteristic  case  of 
chronic  appendicitis  is  given  in  Fig.  174,  which  shows  the  greatly  hypertrophied, 
edematous  walls,  the  circular  canal  at  the  cut  end.  and  farther  out  a  stricture. 


Fig.       173— Chronic 
Appendicitis. 

The  mu i-  mem- 

brane  is  thickened, 
in  ■  ■  ■  m  and  :it  .1  forms 
a  distinct  polyp. 
(Specimen  from  I.  R. 
Trimble.) 


Fig.     174.  —  Chronic 
citis. 
The     appendical     wall 
thickened     and     edematoui 

lii"-r      jip.iiMUiiced      change- 

pearing  in    the  submit' 

canal  i-  strictured  at  one  point 
and  contains  two  soft  concre- 
tion* (0  :ili'  1  '  I,  \t  <1  t  hell'  1-  a 
small  hematoma  of  the  mucous 
membrane.  (Surg.  Path.,  No. 
1358 


Appendi- 


are 
the 
ap- 
The 


Stricture 


Fig.  175. — Chronic  Ap- 
pendicitis, WITH 
Complete  Stricture 

IN    THE     MllHlI.K.     AND 

thi:  Mi  .  mi  a  Mem- 
brane Entirely  Re- 
placed ny  Scab 
Tissue.  (Surg.  Path  . 
No.  4755. 1 


The  mucous  memhrane  is  smooth  ami  devoid  of  the  usual  folds.  At  one  point 
a  small  hematoma  is  elevated  above  the  surrounding  surface.  There  are  two 
soft  concretions  in  the  canal.  Very  frequently  only  a  portion  of  the  mucosa, 
the  distal  half  or  two-thirds,  is  involved  in  an  inflammatory  process,  the  re- 
mainder presenting  the  normal,  pale,  smooth,  glistening  appearance;  or,  again, 
some  portion,  or  almost  the  whole  mucous  memhrane  may  he  replaced  by 
chronic  granulation  tissue  showing  various  stages  of  organization  and  cicatri- 
zation. 

The  appendix  shown  in  Fig.  175  was  removed  after  the  fourth,  and   most 


CHRONIC   APPENDICITIS.  281 

severe  attack  of  inflammation.  It  was  lightly  adherent  to  the  cecum,  brightly 
injected,  and  presented  a  slight  constriction  about  its  middle.  On  section  the 
canal  was  found  to  be  completely  obliterated  at  two  points,  about  5  mm.  apart, 
the  intervening  space  containing  mucus.  The  whole  inner  surface  was  granular, 
or  rugous  and  crossed  by  bands  of  dense  scar  tissue.  The  canal  contained  a 
little  mucus.  Microscopic  examination  revealed  complete  destruction  of 
the  mucous  membrane,  not  a  trace  of  epithelium  or  lymph  nodes  remaining. 
The  surface  in  most  places  showed  coagulative  necrosis  associated  with 
a  mucoid  degeneration  of  the  tissue.  That  the  mucus  was  not  simply  a 
deposit  upon  the  surface  was  shown  by  the  remnants  of  blood-vessels  and  con- 
nective tissue  strands  which  were  traceable  in  it.     The  submucosa  was  fibrous 


:.-- 


-■■*:z?r\\x  ■■■<  -  ■ .:      .,*    _-•-',  ,•*->'" 

••-v^  *v     - 


c 

Fig.   176. — A  Section*  from  the  Preceding  Specimen*.     Magnified  40  Times. 
On  the  left  the  surface  shows  extensive  coagulative  necrosis;  on  the  right  there  is  a  thick  layer  of  a  mucoid 
substance  (a)  containing  traces  of  fibrous  tissue  and  vessels,  a  few  leucocytes,  and  cellular  detritus,     b  is  the 
deeper  portion  of  the  submucosa;  c.  blood-vessels;  and  d,  fat  cells. 

and  edematous,  likewise  the  muscular  coats.  There  was  a  diffuse  infiltration 
of  the  inner  layers,  chiefly  with  plasma  cells.  Here  and  there  a  deposit  of  yel- 
lowish, granular  pigment  was  seen  (see  Fig.   176). 

The  most  marked  changes  are  often  found  in  the  submucosa,  which  appears 
as  a  thick,  dense,  fibrous  band,  sometimes  forming  more  than  half  of  the  entire 
thickness  of  the  walls  of  the  appendix,  the  increase  being  chiefly  at  the  expense 
of  the  mucous  layer.  The  muscular  coats  may  preserve  their  usual  relation  to 
the  other  tissues,  or  may  appear  thicker  or  thinner  than  normal.  The  peri- 
toneum is  usually  thickened,  and  is  exceedingly  vascular.  In  some  instances 
the  different  layers  are  indistinguishable  from  one  another,  and  the  whole  greatly 


282 


PATHllI.dCV. 


thickened  wall  of  the  appendix  appears  to  consist  of  a  homogeneous,  edematous 
fibrous  tissue  which  is  sometimes  strikingly  suggestive  of  a  new  growth.     As 

tlie  following  case  is  unusually  inter- 
esting it  is  given  in  some  detail. 


-V 


••*.-■■ 


J.  B.,  age  fifty  six  (J.  II.  II..  Surg. 
No,  L2942).  Admitted  during  an  attack 
of  appendicitis,  with  a  history  of  Dumer 
ous  similar  attacks  extending  over  a 
period  of  fouryears.  As  the  acute  symp- 
toms subsided,  a  distinct  rounded  mass 
could  easily  be  made  oul  in  the  right 
iliac  fossa.  <  in  operation,  the  vermiform 
appendix  was  discovered  running  out- 
ward   and    slightly    backward    into  the 

iliac  fossa,  where  it  was  ailherenl  by  its 
tip.  It  was  very  large,  extremely  bard, 
and  densely  white.  The  picture  it  pre- 
sented was  a  rather  new  one  in  appen- 
dicitis, the  appendix  being  exceedingly 
edematous  and  infiltrated.  Its  mesen- 
tery was  also  quite  thick,  and  the  amount 
of  induration  in  the  cecum  around  the 
base  of  the  appendix  was  so  greal  that 
when  sutures  were  inserted  in  the  at- 
tempt to  invert  the  stump,  it  proved 
impossible  to  do  so  effectually,  and  there- 
fore drainage  was  thoughl  advisable. 
Convalescence  was  normal,  except  for 
slight  rises  of  temperature  in  the  even- 
ing during  the  fourth  week,  which  could 
probably  be  accounted  for  by  vaccina- 
tion. The  appendix  was  about  1.5  cm. 
in  diameter,  very  resistant  and  hard:  in 
fart,  the  whole  picture  suggested  carci- 
noma. On  cutting  it  open,  the  bulbous 
tip  appeared  to  he  iii  a  condition  of  de- 
generation  which  also  suggested  carci- 
noma (see  Fig.  2.  Plate  III).  The  walls 
were  everywhere  thickened  and  exceed- 
ingly rigid,  but  the  mosl  pronounced 
changes  appeared  in  the  tip,  where  a 
dense  rounded  mass  projected  into  the 
lumen.  This,  as  well  as  the  adjacent 
surface  of  the  mucosa,  was  covered  with 
a    yellowish-white    caseous    material    containing   a    large    amount     of    calcareous 


Fig.  177. — A  Section  from  the  Appendix  Shown 
in  Fig.  -',  l*i. ate  III.  Magnified  16  Times. 
a.  Cellular  detritus  and  calcareous  material,  b, 
the  thick  edematous  submucosal  ('.  the  edematous 
muscularis;  '/.  peritoneum  ami  subperitoneal  lil.i.ti 
layer.  There  is  a  general  infiltration  "1"  lymphoid 
and  plasma  cells,  frequently  collected  in  clump-  and 
along  the  course  of  the  vessels.  (Surg.  Path..  No. 
1086 


.Ill  3TAJS  HO  HOITIIHDZaa 

■(   I, m:  hvfn'    )  ilj    .h  -Jul  mi  /ibasqqf  .       Mgia  .-iji'iib/ioqqj:  'itrr->A — .1    .;ji4 

ire  aoiteiirqqira  lo  i  .oiras 

yl)(nil.')'»')/i  boa  bigri  ,bon<»>Jiiil}  ai  xiba  Iw  oJT     .aiJioii 

I  I'HtTj  r/i(  •!!')  lo  ateiafloo  doidw  Beam  9jliI-nomuJ 
Ilnuis  /      .len  •  I'll'  rUiiidw  c  tliiff 

-in<  gniuiemoi  -nil      .iiaoq9b  rfaiiidw  -iilj  dliv/  bsigyoa 

:      :  .  '■'  I     .-jtriq.  ■ 
.onotg-U^'j  b  gflildni989i  bria  baWsoal  vlr 

!}  lo  ^ninil  zuoium  sdT     .snoi' 

(  vll'i/1  .(-.  .H 


DESCRIPTION  OF  PLATE  III. 

Fig.  1. — Acute  appendicitis,  eight  days.  The  appendix  irregularly  distended  and  hyper- 
emic.     At  b  and  c  foci  of  suppuration  are  visible.     (T.  S.  Cullen.) 

Fig.  2. — Chronic  appendicitis.  The  whole  appendix  is  thickened,  rigid  and  exceedingly 
edematous.  The  tip  is  occupied  by  a  dense  tumor-like  mass  which  consists  of  the  hypertrophied 
edematous  submucosa  covered  with  a  whitish  deposit  containing  calcareous  material.  A  small 
papillary  elevation  near  the  tip  is  also  covered  with  this  whitish  deposit.  The  remaining  sur- 
face is  smooth,  the  mucosa  atrophic.     (VV.  S.  Halsted.) 

Fig.  3. — Enteroliths  in  the  appendix,  one  distinctly  facetted  and  resembling  a  gall-stone. 
(H.  Gushing.) 

Fig.  4. — Mild  subacute  appendicitis.  Soft  fecal  concretions.  The  mucous  lining  of  the  dis- 
tal portion  (a)  is  swollen  and  hemorrhagic.     (H.  A.  Kelly.) 


- 


CHRONIC    APPENDICITIS. 


2s:i 


deposit.  The  cut  surface  of  the  tissue  presented  a  uniform,  fibrillated,  edematous 
structure,  in  which  there  was  no  trace  of  the  normal  layers.  Near  the  tip  one  or 
two  slight  papillary  elevations  were  noticed.  The  histological  examination  showed 
that  section  from  various  regions  presented  a  fairly  uniform  appearance.  On  the 
surface  there  was  a  layer  of  mucus,  and  of  granular,  eosin-stained  material,  con- 
taining cellular  detritus,  with  a  large  amount  of  lime  salts.  Occasionally,  a  single 
layer  of   flattened   epithelium   was   found    resting  directly  upon  the  dense  fibrous 


'    <  •,  .- 


&£     *. 


■m 


a— 


<M 


c 


Fig.    178. — Section  from  the  Preceding  Case,  Showing  Atypical  Glands  and   Mucoid  Degeneration. 

Magnified  -00  Times. 
a.   Edematous  fibrous  stroma  ;  b,  mucus;  r.  glands. 

tissue.  There  were  no  glands  nor  lymph  follicles.  The  greatly  thickened  sub- 
mucosa  consisted  of  edematous  fibrous  tissue,  with  fairly  abundant  fusiform  cells  and 
numerous  thick-walled  blood-vessels  (see  Fig.  177).  Small  round  cells,  and  plasma 
cells  were  fairly  numerous,  usually  occurring  in  small  clumps.  The  line  of  demarca- 
tion between  the  submucosa  and  circular  layers  was  very  indistinct,  and.  indeed, 
could  not  be  determined  with  any  certainty.  The  normal  muscle  bundles  had  disap- 
peared, and  the  individual  fibres  were  separated  by  edematous  fibrous  tissue,  swollen 


284 


PATHOLOGY. 


ami  palely  stained.  The  peritoneal  layer  presented  similar  changes.  At  the  angle 
in  the  sulcus  between  the  tip  and  the  neighboring  wall,  groups  "f  proliferating  glands 
were  found  (*>■<■  1  ijr.  178).  These  areas  were  covered  with  a  thick  layer  of  mucus, 
which  also  filled  the  gland  lumina  and  in  places  surrounded  the  base  of  the  gland, 
apparently  infiltrating  the  fibrous  stroma.  This  mucoid  degeneration  has  been 
noted  in  other  cases  of  chronic  inflammation.  The  glands  were  irregularly  branched, 
their  epithelium  swollen,  and  sometimes,  apparently,  several  layers  thick.  The  cells 
were  mostly  degenerated.  The  glands  exhibited  no  disposition  to  invade  the 
deeper  tissues,  the  appearance  of  invasion  being  due  to  the  fact  that  they  were  in 
an  angle  and  compressed  by  the  proliferating  fibrous  tissue. 

Histology  of  Chronic  Diffuse  Appendicitis. — The  essential  condition  found 
here  is  a  fibrous  tissue  transformation  affecting  to  a  greater  or  less  degree  all  the 

layers  of  the  appendix 
wall.  The  general  fi- 
brous  change  is  accom- 
panied with  sclerosis, 
and  obliterative  changes 
in  the  blood-vessels. 
The  mucous  membrane 
is  usually  edematous, 
the  interglandular  tis- 
sue is  vascular,  more 
fibrous  than  normal, 
and  contains  an  in- 
creased number  of 
lymphoid  ami  plasma 
cells.  Red  blood  cells 
.-ire  often  found  and  in 
many  cases  then'  is  a 
deposit  of  brownish 
granular  pigment  of 
hematogenous  origin. 
Hemorrhage  into  the 
tissue  and  beneath  the  epithelium  may,  according  to  Riedel,  precipitate  a  sud- 
den acute  attack  of  inflammation,  by  injuring  t he  tissue.  The  solitary  follicles 
may  be  greatly  swollen,  forming  a  continuous  zone  of  lymphoid  tissue;  or,  again. 
they  are  to  a  great  extent,  or  wholly,  replaced  by  fibrous  tissue.  The  surface 
epithelium  is  usually  flattened  and  the  glands  are  -hallow  and  compressed  by  the 
infiltrated  interglandular  tissue.  A  few  glands  may  lie  cystic.  In  some  instances 
the  only  trace  of  the  mucous  membrane  consists  of  a  layer  of  flattened  epithe- 
lium, resting  directly  upon  a  layer  of  dense  cicatricial  tissue.  The  submucous, 
muscular,  and  subperitoneal  layers  are  altered  to  a  varying  degree.  As  a  rule, 
the  most  marked  fibrous  tissue  proliferation  is  found  in  the  submucosa,  which 


fc*- 


j! 


\r  ffr/< 


«!'« 


Fig. 


M\..\i 


79. — Obliterative   Kndarteritis   in-   the   Mesappendix. 
hk i'  90  Txhi  -. 
a~a'.   The  ve>>el    lumen:    b,   the  external    elastic   layer   of    the    intima 
thickened  port  ion  of  the  mi  una:  d,  tunica  media;  * .  tunica  externa. 


CHBONIC    APPENDICITIS.  285 

may  be  thickened  out  of  all  proportion  to  the  other  layers.  The  blood-vessels 
of  this  region  have  greatly  thickened  walls,  and  not  infrequently  are  almost 
completely  obliterated.  Small  round  lymphoid,  and  plasma  cells  may  be  very 
abundant,  the  latter  usually  predominating.  A  specimen,  recently  sent  me 
for  examination,  had  been  pronounced  small  round  cell  sarcoma  on  account  of 
the  dense  masses  of  plasma  cells  found  in  the  submucosa. 

In  the  muscular  coats  the  connective  tissue  hyperplasia  occurs  at  the  ex- 
pense of  the  muscle  fibres.  The  subperitoneal  layer  takes  an  active  pari  in  the 
general  fibrous  tissue  increase,  and  usually  shows  sclerotic  changes  in  the  smaller 
blood-vessels.  As  a  rule,  the  larger  vessels  of  the  peritoneal  coat  are  fairly 
normal,  and  the  main  appendical  vessel,  with  its  tributaries,  in  the  mesappendix 
is  almost  constantly  so.  In  rare  instances  the  vessel  walls  are  slightly  sclerotic, 
but  advanced  obliterative  changes  I  have  found  in  only  one  case  (see  Fig. 
179),  which  was  furnished  me  by  Steensland  of  Syracuse,  New  York. 


CHRONIC  ULCERATIVE  AND  PURULENT  APPENDICITIS. 
Chronic  diffuse  inflammation  renders  the  appendix  peculiarly  susceptible 
to  further  infections,  which  may  result  in  an  acute  reaction,  or  in  a  chronic  sup- 
purative condition.  As  pointed  out  by  Lenzmann,  there  may  be  a  concurrence 
of  two  factors  which  expose  the  appendix  to  the  danger  of  further  injury:  the 
ready  reception  of  foreign  material  from  the  cecum,  and  the  more  or  less  pro- 
nounced disability  of  the  appendix  to  free  itself  from  this  material.  A  lurking 
place  for  fecal  particles  with  their  infective  and  putrefactive  contents  is  thus 
created  and  the  abundant  bacterial  development  of  the  cecal  region,  extending 
by  direct  propagation  to  the  appendix,  is  there  further  influenced  by  the  con- 
dition of  stasis  produced  by  the  rigidity  of  the  tissues  and  the  loss  of  muscular 
power.  The  result  of  these  conditions  is  that,  ultimately,  the  increased  bacterial 
activity  associated  with  the  diminished  resistance  of  the  tissue,  produces  more 
or  less  extensive  tissue  necrosis  and  may  excite  an  acute  or  subacute  attack. 
often  characterized  by  suppuration.  Enteroliths  also  exercise  an  important 
influence  in  inducing  tissue  necrosis.  The  necrotic  areas  are  usually  in  direct 
relation  with  the  infective  material  and  may  be  limited  to  the  mucous  mem- 
brane,  or  may  extend  deeper,  sometimes  involving  the  peritoneal  coat.  Some- 
times also  there  may  be  circumscribed  ulcers  having  infiltrated,  irregular  mar- 
gins, the  base  being  covered  with  necrotic  material;  or  there  may  be  a  diffuse 
suppurative  process.  If  the  canal  becomes  obliterated  at  any  point,  a  purulent 
exudate  accumulates  in  the  appendix,  and  a  tensely  distended  pus  sac  results. 
The  size  of  the  mass  depends  partly  upon  the  location  of  the  obstruction,  whether 
close  to  the  cecal  orifice,  or  at  some  distant  point,  and  partly  upon  the  nature 
of  the  infection.  The  slow  accumulation  of  the  purulent  exudate,  and  the  gradual 
distention  in  the  case  of  a  chronic  pyo-appendix,  are  accompanied  by  a  hyper- 
plastic tissue  growth  in  the  walls  of  the  appendix,  which  become  greatly  thick- 


286 


PATHOLOGY. 


ened,  in  some  instances  being  from  .">  to  1(1  mm.  thick.  In  such  a  case  the  normal 
constituents  of  the  appendix  walls  are  entirely  replaced  by  chronic  granulation 
tissue,  rich  in  cellular  elements.  The  inner  surface  is  covered  with  necrotic 
tissue  and  fibrin.    The  mass  rarely  has  a  diameter  of  more  than  2  to  3  cm.,  but 

il   may  attain  enormous  dimensions,  as  in  a  specimen  sent  me  by   G.  MtJLLER 

(see    Fig.     1MII. 

In  some  instances  the  mass  is   freely  movable  and   without    adhesions,   in 

other  cases  the  omentum  may  be  ai 
tached,  bul  most  frequently  it  is  fixed 
by  adhesions  to  the  abdominal  wall 
or  other  neighboring  structures. 

As  in  the  case  of  acute  purulent 
appendicitis,  perforation  may  result 
from  the  extension  of  the  necrosis  to 


Fig.  180.— Empyema  of  the  Appendix. 
At  the  cecal  end  the  greatly  thickened  walls 
completely  occlude  the  canal,  and  the  rest  of  the 
appendix  is  distended  with  pus.  The  whole  interior 
is  lined  with  ragged  necrotic  material.  The  mucous 
and  submucous  layers  are  almost  totally  destroyed, 
hut  in  places  are  represented  by  islands  of  thick- 
ened, degenerated  tissue. 


Fig.     181. — Chronic    Suppurative     Appendicitis 
with  Obliterated  Lumen  at  o,  and  Beyond 

mis   v  Pi  s  Sac  Which  has  Ruptured  (6). 

The  collapsed  condition  of  the  walls  of  tins  por- 
tion shows  that  there  has  been  considerable  disten- 
tion. The  mucosa  here  is  irregular  and  at  a  point 
opposite  the  concretion  (c)  has  been  destroyed. 


the  peritoneal  surface  (see  Fig.  181).  But  in  chronic  suppuration,  more  fre- 
quently than  in  acute  conditions,  the  productive  inflammatory  reaction,  due  to 
the  diffusion  of  toxins,  which  precedes  the  destructive  process,  has  resulted  in 
the  formation  of  a  protective  barrier  which  limits  the  distribution  of  the  infec- 
tion. Moreover,  whereas  in  acute  pyo-appendix  the  virulence  of  the  infective 
agents  is  exalted,  in  chronic  suppuration  the  mild  infection  may  be  limited,  or 


RESIDUAL    APPENDICITIS. 


L>s7 


even  destroyed  by  the  reaction  on  the  part  of  the  tissues. 
follow  the  rupture  and  drainage  of  the  empyema  into  the 
intestine  or  other  hollow  viscus,  or  the  fluid  contents  may 
become  absorbed,  and  the  cavity  finally  obliterated  by 
granulation  tissue. 


Resolution  may 


Fig. 


^^ 


is-'.  —  multiple 
Stricture  in  the 
Appendix. 


RESIDUAL  APPENDICITIS. 

This  term  includes  the  various  deformities  of  the  appen- 
dix which  may  follow  acute  or  chronic  inflammation  after 
the  active  disease  has  subsided.  The  results  may  lie  hyper- 
trophy or  atrophy  of  the  appendix,  stricture  or  obliteration 
of  its  lumen,  cystic  dilatation,  or  angulations  or  twists  due  to 
adhesions  or  cicatricial  contractions  in  the  appendix  wall. 
These  conditions  have  been  already  referred  to,  but  are 
more  conveniently  considered  as  a  distinct  class.  They 
are  of  importance  not  only  on  account  of  their  etiological 
relation  to  recurrent  acute  infection,  but  as  the  usual 
source  of  the  clinical  conditions  described  by  Lenzmann 
and  by  Ewald  as  appendicitis  larvata.  As  has  already 
been  explained,  acute  or  chronic  appendicitis  exceedingly 
rarely  results  in  a  restitutio  ad  inter/rum.  In  the  mildest  cases 
there  is  more  or  less  connective  tissue  hyperplasia,  and  as  a 
consequence  a  certain  amount  of  rigidity  and  enfeebled  mus- 
cular power  persists.  In  the  healing  and  repair  of  erosions,  newly-formed  con- 
nective tissue  replaces  the  destroyed  area,  and  like  all  cicatricial  tissue,  tend.* 
to  contract,  resulting  in  strictures,  angulations,  or  occlusion 
of  a  portion  of  the  canal.  Abbe,  who  has  devoted  much 
attention  to  this  condition  and  is  strongly  impressed  with  its 
pathogenic  importance,  has  prepared  an  excellent  series  of 
specimens  which  show  its  various  grades  as  well  as  the  num- 
ber of  stenoses  which  may  follow  appendicitis.  His  method 
of  distending  the  appendix  with  alcohol  and  thus  hardening 
it  before  sectioning,  has  given  some  excellent  results,  but  it 
is  not  applicable  in  all  cases  and  is  not  always  so  useful  as  the 
examination  of  the  fresh  specimen.  A  typical  example  of 
multiple  stenosis  associated  with  stercoral  concretions,  fur- 
nished by  Rttnyon,  is  given  in  Fig.  1S2.  In  this  case  one  or 
more  attacks  of  mild  inflammation,  possibly  confined  to  the 
inner  layers,  have  been  productive  of  several  areas  of  com- 
plete and  partial  stenosis,  without  at  any  time  having  given 
rise  to  attacks  of  pain  or  tenderness  in  the  abdomen.  The 
appendix  was  removed  during  the  course  of  an  operation  for 


a 


Fig.  183. — Kink    and 
Stricture     Pro- 
duced  by  Adhe- 
sions  in   a  Case 
of    Chronic    Ap- 
pendicitis. 
a.      Kink,        with 
separation      of      distal 
from  proximal  portion 
of    the    appendix;     b, 
adhesion.      The   distal 
portion  is  obliterated. 
(Cyn.       Path.,       No. 
521S.) 


12SS 


l'ATHul.i  )GY, 


myoma.  General  destruction  of  the  mucosa  is  followed  by  total  obliteration 
of  the  canal.  It'  the  canal  is  only  partially  stenosed,  other  factors,  such  as 
kinking  or  the  compression  by  adhesions,  may  make  the  obstruction  complete. 
In  the  appendix  shown  in  Fig.  183,  the  kink  produced  by  the  dense  band  of 
adhesions  has  resulted  in  the  separation  of  the  distal  from  the  proximal  end 


•Submncosa- 


Fig.    184. — Cystit   Appendix    with   the    Proximal    End    (a)    PnoTRrnivo   into   the   Cecum. 
Several  tags  of  adhesion*  are  Been  "'i  the  surface  of  the  cyst.     (Sent  by  E.  E.  Montgomery  from  the  Museum  of 

Jefferson  Medical  ('. .liege.) 


of  the  appendix,  the  two   portions   being  connected   by  the  mesentery  and  a 
band  of  fibrous  tissue. 

Retention  Cysts  of  the  Appendix. — If  a  portion  of  the  canal  distal  to  the 
obstruction  remains  patent,  the  normal  secretion,  having  no  outlet,  accumulates 
in  it  and  a  retention  cyst  is  produced.     The  contents  of  the  cyst  is,  at  first,  com- 


CYSTS    OF   THE    APPENDIX. 


289 


a  muco- 
pressure 

secretion 


A.H°rv 


Fig.   185. — Cystic  Distention  of  the  Lower  THREE-rorRTHs  of  the  Ap- 
pendix due  to  Stricture  of  the  Canal. 
The  proximal  end  is  pervious.     The  surface  of  the  cyst  covered  with  adhesions 
and  markedly  injected.      (Gyn.  Path..  No.  r>718.) 


posed  of  the  normal  mucous  secretion  of  the  appendical  mucosa,  or  of 
purulent,  sometimes  sanguineous  fluid;  but  later,  probably  owing  to 
atrophy  of  the  mucosa   and  consequent  loss  of  function,  the  mucous 
ceases,  and    the  fluid 
becomes     serous     or 
watery  in    character. 
If   the  occlusion    has 
occurred  close  to  the         ^Ufcjfc3 
cecal    attachment    of      JT^^^^Utfr 
the     appendix,     the 
cyst  appears  to  arise 
directly      from      the 

cecum.      In   the  *^vk 

shown    in    Fig.    184  7 

stenosis     had     prob- 
ably taken  place  di- 
rectly   at     Gerlach's 
valve    and    did    not 
involve  the  canal  be- 
yond this  point.     The  thin  membrane  which  obstructed  the  canal  at  the  valve 
became  gradually  distended  by  the  pressure  of  the  fluid  within  the  appendix  so 
that  finally  the  cyst  became  partly  intracecal.     Other  cases  have  been  reported 
in  which  the  cyst    had  developed  almost  wholly  within  the   cecum.      If   the 

obstruction  is  at  a  more 
distant  point  the  cyst 
appears  to  be  peduncu- 
lated, being  attached  to 
the  cecum  by  the  normal 
proximal  portion  of  the 
appendix  (see  Fig.  L85). 
Again,  only  the  tip  may 
be  cystic,  or  the  middle 
of  the  appendix  may  be 
distended  while  the 
proximal  and  distal  por- 
tions are  obliterated. 
The  canal  may  be  oc- 
cluded at  two  or  more 
points,  and  the  interven- 
ing portions  may  become 
cystic. 

An  interesting  case  of  cystic  change  in  the  appendix,  affording  an  unusual 
opportunity  to  observe  the  progress  of  the  disease,  is  shown  in  Figs.  1S6  and 
19 


Fig.  186. — The   Appendix  as  Seen  in  situ,  November.  1S97.  Showing 
a  Single  Cyst  and  Obliterated,  Withered  Distal  Extremity. 


290 


PATHOLOGY. 


ls7,  which  show  the  condition 


Fro.  L87.      I  in    Sahi    Vppi  urn*  (Sbi   I  [Q.  186), 
I: i  movi  i>  Hi  i c .  L903, 

The  obliterate-l   ili-tal   [hhiiuii   h;i     1 me 

much  shortened,  c  probably  repre  enta  the 
original  cyst,  and  a  and  b  are  of  later  develop- 
ment. Cavities  /*  and  c  communicate  with  each 
other.      (Gyn.  Path.,  No.  0996.) 


he  appendix  on  its  removal,  and  the  same 
appendix  as  it  appeared  six  years  previ- 
ously, when,  during  the  course  of  an 
abdominal  operation  it  was  carefully  ob- 
served ami  sketched  by  the  artist,  bul  was 
not  removed,  as  its  condition  at  thai  time 
was  nut  considered  a  menace  to  the  pa- 
tient's welfare.  When  the  appendix  was 
first  observed  there  was  a  single  cysl  in 
the  median  portion,  ami  beyond  this  point 
the  canal  was  apparently  obliterated.  On 
its  removal,  three  cyst   cavities,  separated 

by  fibrous  partitions,  had  formed,  the  later 
ones    having  developed   in   the  proximal 

portion  of  the  appendix.  The  tip  had 
become  considerably  shortened.  The  cyst 
cavities  are  lined  with  a  layer  of  flattened 
epithelium,  which  rests  directly  upon  the 
muscular  coat. 

In  some  instances  secondary  cysts  have 
developed  in  the  remains  of  partly  oc- 
cluded glands.  A  rare  condition  described 
by  RlBBERT,  and  by  KeLYNACK,  and 
ie  pressure  within  the 


which  I  have  observed  in  one  case,  is  produced  when 
appendix  has  caused  a  separation  of  the  musculature, 
and  a  protrusion  beneath  the  peritoneum  of  the  lining 
membrane  with  its  mucous  or  serous  contents.  In 
Kelynack's  case  two  distinct  diverticula,  which  com- 
municated with  the  main  cavity  by  circular  openings, 
extended  between  the  layers  of  the  mesappendix. 
In  my  case  there  was  a  single  hernia-like  protrusion 
into  the  mesentery.  The  influence  of  a  kink  or  twist 
in  producing  the  cystic  condition  may  be  seen  in 
some  cases  in  which,  upon  separating  the  mesappen- 
dix or  the  adhesions  which  produce  the  kink,  the 
fluid  immediately  escapes  into  the  cecum.  This 
probably  explains  some  cases  in  which  a  distinct 
mass  is  easily  palpable,  while  at  operation  only  a 
small  appendix  is  found,  which  is.  however,  unusually 
flaccid,  and  has  the  appearance  of  having  been  dis- 
tended. 

Cysts  of  the  appendix  as  a  rule  are  cylindrical  in 
form  and  vary  in  size  from  about  the  thickness  of  a  lead-pencil  to  from  one  to 


Fig.      188. — Cystic      Af-ii      m... 
(Gyn    Path.,  No.  2170.) 


CYSTS    OF   THE    APPENDIX.  L'01 

three  centimetres  in  diameter.     In   exceptional   instances  very  large   masses 

develop.  One  described  by  Sonnenburg  was  an  enormous  pear-shaped 
cyst,  14  cm.  in  length,  and  21  cm.  in  its  greatest  circumference.  Virchow  de- 
scribed a  case  in  which  the  appendix  was  as  large  as  a  fist.  The  walls  of  the 
cystic  appendix  are  attenuated  and  transparent.  The  peritoneal  surface  often 
presents  a  few  adhesions,  but  may  be  perfectly  smooth.  The  inner  surface  i- 
usually  smooth  and  glistening.  Figs.  Inn  and  ls5  are  characteristic  examples  of 
the  cystic  appendix.  The  former  is  situated  directly  upon  the  cecum  and  has  a 
smooth  surface,  while  the  latter  is  covered  with  adhesions  and  has  a  long  pedicle. 


•>.'4-t.  ..U. 


Mag.  T 


■•'■■>  .-"iS-"  "?s'?*^*?5w?SBKr 


Fig.  189. — Section-  from  the  Preceding  Case  07ig.   188)  or  Cystic  Appendix. 
The  small  picture  on  the  left  shows  the  diluted  lumen  and  tlunned-out  walls.     The  area  between  the  two 
dotted  line-  I-  -een  highly  magnified,  in  the  picture  on  the  right   side.      The  mucous  membrane  is  represented 
by  a  layer  of  flattened  epithelium  re«tina  upon  a  layer  of  libr..u-  tissue.      A  small  flattened  lymph  node  is  seen 
near  the  edge  of  the  picture.     There  is  a  general  round  cell  infiltration  of  all  the  coats. 

Histologically,  a  general  connective  tissue  proliferation  is  apparent  with  a  corre- 
sponding loss  of  the  normal  elements  of  the  appendix  walls.  The  whole  picture 
is  that  of  a  mild,  chronic,  inflammatory  reaction  associated  with  pressure  atrophy 
of  the  tissues.  The  mucosa,  as  a  rule,  is  represented  by  a  single  layer  of  low 
columnar  or  cuboidal  epithelium  resting  directly  upon  a  layer  of  fibrous  tissue. 
(Hands  have  usually  disappeared.  An  occasional  small,  flattened  lymph  node 
may  be  seen.  In  many  cases  the  muscular  coats  are  almost  entirely  replaced 
by  fibrous  tissue,  but  in  some  instances  the  muscle  bundles  are  fairly  well  pre- 
served.    As  a  rule,  there  is  a  slight  diffuse  round  cell  infiltration  (see  Fig.  189). 


292  PATHOLOGY. 

Obliteration  of  the  Appendix.— Considerable  attention  lias  been  recently 
directed  to  obliterative  changes  in  the  appendix.  Ribbert,  Wolfler,  and 
Zuckerkandl,  from  the  careful  examination  of  a  large  number  of  cases,  all  ar- 
rived at  the  conclusion  thai  obliterative  changes  in  the  appendix  arc  not  the 
result  of  an  inflammatory  process,  but  an  involution  process  in  a  functionless 
organ.  Cri  veilhier,  Bierhofp,  Fitz,  Senn  ami  others  believe  that  oblitera- 
tive changes  have  a  pathological  origin.  Tchacaloff,  in  19  cases  of  partial  or 
total  obliteration,  found  in  all.  distinct  evidence  of  a  pathological  process. 

My  investigations  have  dealt  chiefly  with  specimens  removed  at  operation, 
and  only  to  a  limited  extent  with  autopsy  material,  as,  unfortunately,  the  macro- 
scopic appearance  of  the  appendix  alone  was  noted  in  the  autopsy  protocol-;, 
and  the  specimens  were  not  preserved.  For  the  consideration  of  normal  in- 
volutional^' processes,  see  Chap.  VI. 

In  the  gynecological  service  at  the  Johns  Hopkins  Hospital  it  has  for  some 
years  been  the  rule  to  examine  the  appendix,  if  accessible,  whenever  the  ab- 
domen is  opened  for  any  reason,  and  if  it  presents  any  deviation  from  the  nor- 
mal, however  slight,  it  is  removed,  provided  always  that  there  is  no  special  liar 
to  the  operation.  Thus,  it  has  been  the  custom  to  remove  the  appendix  if 
thicker  <>r  firmer  than  normal,  even  if  the  rigidity  is  very  slight,  or  merely  in- 
volves the  tip.  ( )n  this  account  it  has  been  possible  to  examine  a  large  num- 
ber of  specimens  showing  obliteration,  and  sufficient  evidence  has  been  ob- 
tained from  these  cases  to  warrant  some  conclusions  regarding  the  origin  of 
many  cases  of  partial  and  complete  obliteration  of  the  appendix,  although  no 
definite  conclusion  can  be  reached  regarding  the  relative  frequency  of  its  oc- 
currence. The  opportunity  to  inspect  and  remove  the  appendix  occurs  most 
frequently  in  the  course  of  gynecological  operations;  in  the  general  surgical 
department  the  approximately  normal  appendix  is  less  frequently  removed. 
This  probably  accounts  for  the  fact  that  in  the  material  from  the  gynecological 
operating  room  I  have  found  2]  cases  of  complete  obliteration  of  the  canal  of  the 
appendix,  but  only  two  such  cases  among  the  specimens  from  the  surgical 
department,  although  in  the  latter,  twice  the  number  of  appendices  had  been 
removed.  Partial  occlusion  of  the  canal  occurred  in  about  equal  proportions 
in  the  two  series  of  cases.  In  considering  the  etiology  and  pathology  of  ob- 
literation of  the  appendix,  I  have  chiefly  studied  the  specimens  from  the  gyneco- 
logical department. 

Out  of  300  specimens,  4.">  were  found  to  present  some  degree  of  obliteration, 
varying  in  extent  from  a  small  portion  of  the  tip  to  the  occlusion  of  the  entire 
canal.  Under  this  group  I  have  not  included  cases  of  appendix  with  greatly 
thickened  walls  ami  narrowed  but  patent  lumen,  as  these  are  manifestly  of 
inflammatory  origin;  nor  do  I  include  simple  strictures,  which  have  clearly 
resulted  from  cicatrization  of  erosions. 

The  45  cases  comprise  21  in  which  the  lumen  is  entirely  obliterated,  and  24 
in  which  the  lumen  is  partly  so.  In  the  specimens  showing  partial  obliteration, 
the  extent  of  the  occluded  portion  varied  from  about  1  cm.  at  the  tip,  to  a  half 


OBLITERATION'    OF    THE    APPENDIX. 


293 


or  three-fourths  of  the  length  of  the  organ.  In  one  instance  only,  a  few  milli- 
metres of  the  proximal  end  was  provided  with  a  central  lumen.  With  a  few 
exceptions  the  obliteration  extended  from  the  tip  inward,  the  occluded  part 
forming  a  solid  cord.  In  one  case,  previously  described,  the  proximal  and 
distal  thirds  were  obliterated,  while  the  middle  third  was  cystic.  In  8  cases 
the  proximal  end  was  obliterated  and  the  part  beyond  cystic,  the  occluded  por- 
tions  in  these  cases  varying  from  a  few  millimetres  to  several  centimetres;  in 
one  ease  only  the  distal  third  remained  patent.  These  cases  of  cystic  changes 
in  the  appendix  have  already  been  considered.  The  obliterated  appendix  may 
he  thickened,  firm,  ami  cylindrical  (see  Fig.  190).  or  it  may  he  reduced  to  a  thin 
fibrous  cord  or  flattened  hand  (see  Fig.  191).  In  cases  of  partial  obliteration, 
also,  the  affected  area  may  be  either  hypertrophied  or  atrophied.  If  only  the 
tip  is  involved  the  appendix  may  have  a  clubbed  appearance,  or  may  dwindle 
away  to  a  fibrous  cord.     "When  the  median  portion  is  obliterated  the  organ 


Fig,   190. — Hypertrophied  Appendix  with  Obliterated 
Lumen.      (Natural  Size.) 

There  were  a    few  slight    adhesions  in   the  vicinity  of    the 
appendix.     (Gyn.  Path.,  No.  3S59.) 


Fig.  191. — Atrophied  Appendix  with  Ob- 
literated   Lumen.     (Natural  Size.) 
Fine    adhesions    over    the     middle    i 
(Gyn.  Path..  No.  2884 


may  be  divided  into  two  distinct  portions  connected  by  a  narrow  fibrous  cord 
(Fig.  192).  A  withered  appendix,  when  retrocecal  and  extraperitoneal,  or 
covered  with  adhesions,  may  readily  be  overlooked  and  the  case  regarded  as  an 
instance  of  absence  of  the  appendix.  Fig.  193  represents  a  specimen  which 
was  found  in  a  medical  museum  labeled  "  absence  of  the  appendix  vermiformis." 
The  appendix  in  this  case  was  regarded  as  part  of  the  dense  adhesions  which 
were  found  about  the  cecum,  and  the  complete  absence  of  any  indication  of  an 
appendical  orifice  in  the  cecum  supported  this  view.  Careful  inspection,  how- 
ever, revealed  a  more  definite  outline  than  in  the  case  of  the  surrounding  adhe- 
sions, and  a  section  examined  under  the  microscope  showed  the  usual  muscular 
layers  of  the  appendix,  the  lumen  having  been  replaced  by  fibrous  tissue. 

In  all  but  19  of  my  cases  the  surface  of  the  appendix  presented  evidence  of 
adhesions.     The  adhesions  were  dense  in  some  cases,  but  more  often  they  were 


294 


I'ATIIol.m.l  . 


very  delicate.  The  color  of  the  appendix  was  always  distinctly  paler  than 
normal,  although  occasionally  the  superficial  blood-vessels  were  dilated.  When 
the  obliteration  involved  only  a  part  of  the  appendix,  it  could  at  once  lie  recog- 
nized l>v  tin'  color  as  compared  with  the  rest  of  the  organ. 

( Iross-sections  of  the  obliterated  appendix  examined  by  the  naked  eye  usually 
revealed  two  distinct  layers,  namely,  an  outer  layer  consisting  of  the  muscula- 
ture,   and    a    central 
layer    consisting     of 
fibrous     tissue.      The 

relative  proportions 
of  these  layers  is 
quite  variable.     As  a 

rule,  the  muscular 
coal  is  of  about  nor- 
mal thickness,  hut  it 
is  sometimes  greatly 
thickened,  in-  it  may 
Similarly,  the  central  fibrous  tissue 
may  he  abundant,  or  nun-  have  undergone  considerable  shrinkage.     To  a  great 


Fig.    I9J  -  Ciikumi'  Appendicitis  wiih   Stricture. 

Tiie  distal  portion  is  completely  obliterated,  but  the  proximal  end  is  perviou 

and  shows  an  active  inflammatory  process.     (Surg   No.,  9068 


be  atrophied  and  scarcely  distinguishable, 


Fig.    193. — Obliterated   Appendix   Covered  with   Adhesion's  and   Hidden    Behind   the    [leuh. 
The  cecal  end  of  the  appendix  (a)  can  scarcely  l>e  distinguished  from  the  muscular  bands.     Advancing  toward 
the  tip  it  becomes  more  cylindrical  and  thicker  [h,  r,  d) .  again  diminish  ine  in  size  at  (e). 

The  right-hand  picture  shows  the  interior  of  the  cecum  and  the  normal  site  of  the  appendical  orifice. 


extent  this  variability  depends  upon  the  stage  of  the  affection,  but  not  entirely, 
as  some  very  thick  appendices  show  a  very  thin  muscle  layer;  while  in  others  of 


OBLITERATION   OF   THE    APPENDIX.  29.J 

the  same  diameter  there  may  be  a  broad  band  of  muscle :  and.  again,  a  withered 
appendix  may  have  a  relatively  well  developed  muscle  coat,  or  it  may  consisl 
almost  wholly  of  fibrous  tissue. 

The  m  i  c  r  o  s  c  o  p  i  c  picture  of  t  li  e  obliterated  a  p  p  e  n  - 
d  i  x  is  a  varied  one.  the  characteristic  appearance  depending  partly  upon  the 
stage,  but  chiefly  upon  the  character  of  the  pathological  process.  A  cross- 
section  of  a  thickened,  obliterated  appendix  may  show  any  of  the  following 
conditions  in  the  centre: 

1.  A  centre  of  cellular  fibrous  tissue  containing  remnants  of  lymph  follicles 
or  glands,  and  sometimes  both-  Occasionally  a  microscopic  triangular  or 
irregular  slit  represents  the  former  canal.  This  has  no  special  cell  lining,  and 
as  the  tissue  contracts  will  probably  disappear.  The  remnants  of  lymph  folli- 
cles and  glands  which  are  present  indicate  an  early  stage  of  the  obliterative 
process,  anil  they  also  will  finally  disappear.  The  submucosa  is  thickened, 
fibrous,  and  contains  more  or  less  fat,  usually  only  a  moderate  amount,  while 
numerous  blood-vessels  radiate  to  the  centre.  There  is  often  a  slight  round 
cell  infiltration  of  the  submucosa. 

2.  The  centre  is  fibrous  and  contains  no  remnants  of  mucosa.  The  tissue 
may  be  fairly  cellular  and  contain  numerous  lymphoid  elements,  but  no  well- 
formed  follicles.  The  surrounding  tissue  is  usually  dense,  fibrous,  and  may  con- 
tain very  little,  or  a  moderate  amount  of  fat. 

3.  The  centre  consists  of  fibrous  tissue,  poor  in  connective  tissue  cells,  and 
free  from  lymphoid  elements.  The  surrounding  tissue  often  contains  a  large 
amount  of  fat.  In  one  of  my  cases  the  thickened  obliterated  appendix  showed 
a  rather  thin  musculature  surrounding  a  mass  of  adipose  tissue  with  a  fine  cen- 
tral strand  of  fibrous  tissue,  formed  by  the  intersecting  fibres  of  the  framework 
of  the  adipose  tissue.     This  appendix  was  also  surrounded  by  a  mass  of  fat. 

In  the  majority  of  my  sections  I  have  found  a  deposit  of  brown  granular 
pigment  in  the  obliterated  areas. 

The  muscular  coats,  as  a  rule,  are  of  about  the  usual  thickness.  Either 
layer,  or  both,  may  be  thicker  than  normal,  or  may  be  attenuated.  The  in- 
crease in  thickness  may  be  due  to  hyperplasia  of  muscle,  but  is  often  due  to 
connective  tissue  proliferation,  while  the  muscle  itself  is  diminished  in  amount. 

The  peritoneal  mat.  where  it  is  free  from  adhesions,  is  usually  normal,  but 
may  be  thickened.  A  high  degree  of  sclerosis  of  the  blood-vessels  is  generally 
visible  in  all  the  different  layers,  but  is  especially  marked  in  the  submucosa. 

The  withered  appendix  rarely  shows  any  trace  of  the  mucous  membrane. 
The  central  fibrous  tissue  is  dense,  and  its  outer  zone,  which  represents  the  sul>- 
mucosa.  contains  little  or  no  fat.  The  muscular  coats  may  lie  well  preserved. 
but  usually  there  i<  fibrous  tissue  proliferation  at  the  expense  of  muscle  tissue. 
Sometimes  the  muscle  has  practically  disappeared.  In  one  of  my  eases  all  that 
remained  was  a  narrow  band  along  the  mesenteric  border.  In  the  section  rep- 
resented in  Fig.  194  the  muscular  coats  are  relatively  thick  and  well  preserved. 
The  central  fibrous  tissue  is  dense  and  contains  a  small  amount  of  fat. 


296 


PATHOI.OCY. 


In  both  the  hypertrophic  and  atrophic  forms  of  obliteration  I  have  usually 
found  a  complete  absence  of  lesions  affecting  the  nerve  elements.  In  most 
cases  the  oerves,  owing  to  the  paucity  of  cells  in  the  surrounding  tissue,  appear 
to  be  unusually  prominent.  Morris  observed  the  implication  of  the  nerves  in 
cases  of  obliterated  appendix,  and  in  this  way  explained  the  sense  of  discomfort 
from  which  the  patient  suffered.  However,  in  the  light  of  the  knowledge  ob- 
tained from  numerous  recent  observations  and  experiments,  demonstrating  the 

absence  of  sensory  lien  es  in 
-.  . ■_,  •  the     appendix,    the     clinical 

symptoms  cannot  be  referred 
directly  to  nerve  lesions. 

In  a  partly  obliterated 
appendix,  the  canal  of  the 
patent  portion  may  be  of 
normal  size  and  shape  and 
the  mucous  lining  little,  if  at 
all  altered.  Very  often,  how- 
ever, the  canal  is  circular  and 
the  walls  more  or  less  rigid. 
As  in  diffuse  chronic  inflam- 
mation, the  surface  of  the 
mucosa,  instead  of  presenting 
the  usual  folds,  is  smooth  and 
even;  the  epithelium  is  often 
a  little  flattened;  the  inter- 
glandular  tissue  shows  some 
degree  of  fibrous  change. 

In  some  cases  a  gradual 
transition  from  the  normal 
patulous  condition  to  the 
completely  obliterated  por- 
tion may  be  traced.  In  one 
of  my  cases  where  the  appen- 
dix was  4  cm.  long  and  II 
mm.  in  diameter,  the  lumen 
was  obliterated  except  for  a 
few  millimetres  of  the  prox- 
imal end,  the  canal  became  narrower,  the  mucosa  became  atrophic,  the  glands 
diminished,  and  then  disappeared,  and  finally  the  mucosa  was  replaced  by 
fibrous  tissue  which  completely  occluded  the  canal.  In  other  instances  the 
transition,  instead  of  being  gradual,  is  abrupt.  The  canal  may  be  entirely  nor- 
mal to  a  certain  point,  then  suddenly  cease.  In  the  case  shown  in  Fig.  192  the 
appendix  has  a  lumen  of  normal  calibre  to  a  point  where  it  is  suddenly  reduced 


W 


.    fl  ' 


Fig.   194. — Section  from  the  Specimen*  Shown  in  Fig.  191. 
The  centre  consists  "I  dense  fibrous  tis-ue  containing  a  moderate 
amount  of  fat.      The  circular  muscular  coat   is  atrophic,  the  longi- 
tudinal layer  well  developed.     The  walls  of  the  blood-vessels  in  the 
mesappendix  are  somewhat  sclerotic.     (Gyn.  Path.,  No.  2884.) 


OBLITERATION"    OF    THE    APPENDIX. 


297 


to  a  narrow  impervious  fibrous  cord.  The  distal  portion,  although  of  the  usual 
size  is  also  obliterated.  The  appendix  was  removed  at  operation  after  the  fifth 
severe  attack  of  inflammation.  At  the  time  of  operation  the  constricted  middle 
portion  was  bound  down  by  dense  adhesions. 

In  cases  where  the  obliteration  is  limited  to  a  small  area  near  the  centre  of 
the  appendix,  the  proximal  end  may  be  perfectly  normal,  the  distal  portion 
cystic,  and  the  obliterated  area  not  more  than  one  or  two  millimetres  in  extent. 
Such  a  condition  can  only  be  explained  by  the  adhesion  of  opposite  sides,  as  a 
consequence  of  erosion. 

It  appears  to  me  also  that  a  pathological  origin  best  explains  such  conditions 
as  are  found  in  Fig.  192.     The  irregularity  of  the 
median  portion  and  the  pronounced  thickening  in 
other  regions  can  hardly  be  accounted  for  on  the 
basis  of  a  normal  process  of  involution. 

The  majority  of  my  specimens  showed  indubit- 
able evidence  of  an  antecedent  inflammatory  pro- 
cess, chiefly  in  the  presence  of  adhesions,  which 
were  found  in  about  60  per  cent,  of  the  cases. 
The  presence  of  pigmentary  changes  in  some 
pointed  to  a  former  pathological  process,  while  in 
others,  again,  an  active  inflammation  still  existed 
often  in  the  absence  of  adhesions. 

The  examination  of  numerous  appendices  re- 
moved shortly  after  the  subsidence  of  an  acute 
inflammatory  attack  demonstrates  most  convinc- 
ingly the  method  of  procedure  in  the  production 
of  obliteration.  These  specimens  still  show  more 
or  less  of  an  active  inflammatory  reaction,  chiefly 
evidenced  by  a  leucocytic  infiltration.  In  some, 
pronounced  hypertrophy  of  the  walls  has  taken 
place,  while  the  lumen  is  reduced  to  almost  micro- 
scopic size;  other  specimens  show  cicatrization  of 
erosions,  producing  irregular  constrictions,  which 
eventually  will  contract  and  probably  cause  occlu- 
sion of  the  canal  at  that  point.  Fig.  175  represents  an  appendix  removed  during 
an  attack  of  inflammation.  In  this  case  the  canal  is  still  patent,  but  the  entire 
mucosa  has  been  replaced  by  fibrous  tissue  which  is  beginning  to  contract,  and 
it  is  probable  that  in  this  case,  also,  complete  obliteration  would  be  the  ultimate 
result. 

A  recent  case  of  acute  appendicitis  affords  a  further  proof  of  the  inflamma- 
tory nature  of  obliteration  in  some  cases:  sections  from  the  distal  half  of  the 
specimen  show  the  surface  of  the  mucosa  completely  destroyed  and  the  oppo- 
site sides  adherent  to  one  another  by  a  fibrous  exudate,  which  shows  beginning 


Horn. 


Fig.  195. — Obliteration*  of  the 
Lower  Two-thirds  of  the 
Appendix. 

The  upper  thin]  distended  with 
pus  and  perforated.  Removed  dur- 
ing the  twenty-sixth  attack. 


L".)S  PATHOLOGY. 

organization.  Sections  from  the  proximal  end  of  the  same  specimen  show  here 
and  there  small  areas  of  flattened  surface  epithelium,  while  the  remaining  surface 
consisted  of  granulation  tissue.  The  wall-  generally  are  infiltrated  with  leuco- 
cytes. The  result  in  this  case  would  certainly  have  been,  ultimately, an  obliterated 
distal  end.  and  an  obliterated  or  stenosed  proximal  portion.  Total  oblitera- 
tion of  the  canal  insures  perfect  immunity  from  further  attacks,  but  if  any  por- 
tion remains  pervious,  the  disposition  to  repeated  attacks  increases  with  each 
succeeding  one.  The  specimen  shown  in  Fig.  195,  furnished  by  C.  Beck,  was 
removed  from  a  woman  sixty-eight  years  old  who  had  had  twenty-six  attacks 
of  appendicitis,  and  demonstrates  the  danger  still  lurking  in  the  diseased  organ. 


CONCRETIONS. 

The  role  of  concretions  and  foreign  bodies  in  the  production  of  inflammation 
of  the  appendix  will  be  discussed  in  another  section,  but  the  nature  and  origin 
of  concretions  are  more  appropriately  considered  in  connection  with  the  path- 
ology  of  the  appendix. 

It  has  been  noted  above  that  the  normal  appendix  often  contains  fluid  fecal 
material  which  readily  enters  from  the  cecum,  and  is  as  readily  expressed  back 
into  it.  Fecal  material  exhibiting  various  degrees  of  inspissation  is  also  fre- 
quently found  in  the  appendix,  and  sometimes  forms  rather  firm  cylindrical 
masses  which  conform  to  the  shape  of  the  canal  in  which  they  are  contained. 
While  these  masses  may  appear  somewhat  dense  they  are  quite  friable  and 
consist  almost  wholly  of  undigested  food,  and  other  foreign  material,  together 
with  a  small  amount  of  mucus,  and,  occasionally,  a  few  leucocytes  and  epithe- 
lial cells.  True  enteroliths  are  much  rarer,  and  are  found  in  only  a  small  per- 
centage of  cases.  These  are  exceedingly  dense,  and,  unlike  the  softer  ma----. 
are  often  rounded  in  outline  and  cause  a  distinct  bulging  of  the  appendix  walls. 
Apart  from  their  pathogenesis,  the  chief  points  of  interest  in  regard  to  concre- 
tions are  their  structure  and  the  factors  concerned  in  their  development.  In 
former  times  it  was  the  generally  accepted  view  that  concretions  lodged  in  the 
appendix  were  pre-formed  in  some  other  part  of  the  intestinal  canal,  or  in  the 
gall-bladder,  and  later  worked  their  way,  or  were  forced  into  the  appendix.  A 
glance  at  the  anatomical  structure  of  the  appendix  shows  that  in  the  majority 
of  cases  it  would  be  impossible  for  an  enterolith,  not  one-quarter  the  size  of 
many  actually  found  there,  to  pass  through  such  a  narrow  channel.  The  diffi- 
culty is  further  enhanced  by  the  angle  of  attachment  of  the  appendix,  which 
causes  almost  complete  closure  at  the  site  of  Gerlach*s  valve.  I  would  not  go 
to  the  extent  of  some  writers  who  deny  the  possibility  of  gall-stones  or  enter- 
oliths being  forced  into  the  appendix,  but  I  believe  such  accidents  are  extremely 
rare.  Where  the  fetal  type  of  appendix  persists,  foreign  bodies,  including  gall- 
stones, could  readily  enter  the  wide  appendico-cecal  orifice.  The  normal  re- 
verse peristaltic  contractions  of  the  colon  may  possibly  aid  in  forcing  the  mass 


CONCRETION'S. 


299 


from  the  cecum  into  the  appendix.     The  fact,  however,  that  bodies  exactly 
resembling  gall-stones  are  found  in  appendices,  in  which  it  is  manifestly  certain 
that  the  calculus  must  have  been  formed  in  situ,  and  that  these  bodies,  on  chemi- 
cal and  microscopical  examination  have  shown  the  presence  of  a  nucleus  of 
organized  matter  surrounded  with  layers  of  inorganic  salts,  makes  us  hesitate 
to  accept  any  such  cases  as  genuine  examples  of  gall-stones.     The  presence  of 
cholesterin  does  not  necessarily  indicate  a  gall-bladder  origin,  although  large 
amounts   of    cholesterin   are   not    often    found    in    enteroliths.     Nor   does    a 
facetted  surface  imply  that  the 
stone  was  formed  in  the  gall- 
bladder, as  they  are  occasion- 
ally seen  in   the  appendix.     A 
diagnosis  of  gall-stones  in   the 
appendix  was  made  in  the  case 
presented  in  Fig.  3,  Plate  III, 
partly    on    account    of    the   fa- 
cetted surfaces,  but  chiefly  be- 
cause   the    patient    had    been 
operated  on  a  short  time  previ- 
ously for  gall-stones  in  the  gall- 
bladder.    Later  examination  of 
the  calculus,  however,  revealed 
a  nucleus  of  organized  matter 
and  the  usual  structure  of  en- 
teroliths. 

A  convincing  additional 
proof  as  to  the  formation  of  the 
appendical  concretion  in  situ 
rather  than  in  some  other  por- 
tion of  the  intestine,  is  found  in 
the  characteristic  architectural 
arrangements  of  the  enterolith 
itself,  and  in  the  relation  which 
its  chief  constituents  bear  to 
the  appendix  walls. 

Macroscopical  Ap- 
pear a  n  c  e. — The  concretions,  as  a  rule,  are  ovoid  or  spherical  and  have  a 
dense,  more  or  less  smooth,  polished  surface  (see  Fig.  196).  The  color  is  a  dark 
brown.  It  is  common,  however,  to  find  the  dark  smooth  surface  partly  covered 
with  a  grayish-white  deposit  of  lime  salts.  Section  through  the  centre  shows 
that  the  interior  is  lighter  in  color  and  more  friable  than  the  surface.  There  is 
usually  a  nucleus  consisting  of  a  fragment  of  foreign  material,  and,  surrounding 
this,  concentric  layers  of  a  substance  largely  composed  of  lime  salts. 


Fig.     196. 


-Appendix    Containing    Spherical    Concretion. 
(Surg.  No..  3248.) 


;>llll  r\  i  HOLOGl  . 

II  i  g  i  ological      E  x  a  m  inatio  a  . — Tlie     histological    examination 

shows  that  the  most  important  factor  in  the  formation  of  the  calculus  is  the 
mucus  secreted  by  the  glands  of  the  mucous  membrane.  The  mucus,  which  is  i h-- 
I  in-iic.  I  in  layers  around  the  central  nucleus,  becomes  desiccated,  ami  the  lime  salts 
are  deposited  secondarily.  Frequently,  fragments  of  epithelium,  a  few  leucocytes 
and  altered  blood,  are  found  in  different  layers.  RiBBEHT  noted  that  in  favor- 
able specimens  stained  with  Weigert  's  fibrin  stain,  the  outer  layer  of  mucus  may 

he  soon  to  he  directly  continuous  with  the  contents  of  the  glands  of  I.iehorkiilm. 
In  one  case,  besides  the  two  large  enteroliths  in  the  canal  of  the  appendix,  1 
found  three  smaller  bodies  embedded  in  the  mucous  membranes,  which  had 
evidently  developed  within  gland  lumina. 

M  e  t  h  o  d  of  D  e  v  e  1  o  p  m  e  n  t  . — Normally,  the  fecal  particles  which 
enter  the  appendix  are  returned  to  the  cecum  by  means  of  die  peristaltic  con- 
tractions of  the  appendix  walls.  If,  however,  the  muscular  power  is  en- 
feebled in  any  way,  or  if,  through  the  shape  or  size  of  the  fecal  mass,  or  for  any 
other  reason,  as,  for  example,  the  presence  of  a  kink  or  stricture,  an  impedimenl 
is  offered  to  the  progress  of  the  mass  toward  the  cecum,  it  is  retained  within  (he 
appendix  and  undergoes  various  changes.  The  fluid  portion  is  gradually  ab- 
sorbed and  the  mass  becomes  more  or  less  inspissated.  While  the  drying  pro- 
cess is  taking  place  there  is  a  constant  factor  at  work,  which  is  largely  respon- 
sible for  the  increase  in  the  size  and  density  of  the  mass,  namely,  bacterial 
activity.  The  effort  of  the  appendix  to  expel  the  foreign  material  is  attended 
with  more  or  less  congestion  and  edema,  and  thus  a  favorable  opportunity  is 
provided  for  the  activities  of  the  micro-organisms  contained  in  the  mass  itself. 
These  organisms,  which  are  often  of  a  low  degree  of  virulence,  excite  a  mild 
catarrhal  inflammatory  reaction,  chiefly  marked  by  an  increased  secretion  of 
mucus.  There  is  also  a  slight  leucocytic  infiltration  and  some  exfoliation  of 
the  surface  epithelium.  The  congestion  of  the  mucosa  is  often  associated 
with  slight  interstitial  hemorrhages,  indicated  by  the  deposit  of  pigment  in  the 
interglandular  tissue,  and  by  the  presence  of  altered  blood  in  the  concretion. 

The  increased  mucus  secretion  is  the  chief  factor  in  the  formation  of  the 
calculus.  The  mucus  is  deposited  upon  the  surface  of  the  dried  fecal  particle 
or  other  nucleus,  and  as  it  is  deposited,  becomes  desiccated,  and  later  mixed 
with  lime  salts.  The  influence  of  the  continued  bacterial  activity  in  promoting 
a  separation  of  calcareous  material  from  the  mucus  secretion,  has  been  demon- 
strated by  the  experiments  of  Galipe  (cited  by  Labarthe).  This  writer,  placing 
some  saliva  in  a  Mask,  added  micro-organisms  which  began  to  develop  there,  and 
soon  after  crystals  of  calcium  carbonate  were  deposited  upon  the  saliva.  A 
chronic  cat  a  r  r  h  a  1  cholecystitis  associate*  1  with  the  presence 
of  micro-organisms  of  low  virulence  is  generally  conceded  to  be  of  chief  im- 
portance in  the  production  of  gall-stones,  and  there  is  sufficient  evidence  to 
show  that  a  similar  condition  is  an  equally  important  factor  in  the  formation 
of  enteroliths  in  the  appendix. 


CONCRETIONS.  301 

The  concretion  gradually  increases  in  size  as  the  layers  of  altered  mucus  and 
lime  salts  are  added,  while,  pari  passu,  the  walls  of  the  appendix  expand 
and  usually  become  somewhat  attenuated,  until  finally  the  glands  disappear  and 
the  secretion  of  mucus  ceases. 

The  spherical  form  of  most  calculi  found  in  the  appendix  is  supposed  by 
some  writers  to  lie  possible  only  when  the  mass  has  formed  in  a  free  space,  and 
on  this  account  the  concretions  are  believed  to  enter  the  appendix  from  the 
cecum,  but,  as  we  have  seen,  a  microscopic  examination  shows  that  the  mucus 
which  goes  to  form  the  calculus  is  derived  from  the  glands  of  the  mucous  lining 
of  the  appendix.  A  particularly  instructive  case  in  this  connection  is  seen  in 
one  of  my  own  series.  In  this  instance  the  appendix,  which  had  given  rise  to 
no  clinical  signs,  was  removed  during  the  course  of  an  operation  for  myoma  of 


§^?%"  ■  "Qg^0^:0% 


^ 


Fig.    197. — Mccors   Membrane.  Showing    Impression   of  the    Enterolith   Seen   in    Fig.    232.     Magnified 

25  Times. 
The  mouth  of  a  gland  (a-b)  is  widely  dilated  by  a  projecting  point  of  the  concretion.     (Gyn.  Path.,  No.  2041.) 

the  uterus.  It  was  free,  but  was  excised  on  account  of  the  large  calculi  which 
it  contained.  The  appendix  is  15  cm.  long,  its  middle  third  is  distended  with 
a  spherical  concretion  12  mm.  in  diameter,  and  from  here  to  the  tip  a  cylindrical 
concretion  12  by  6  mm.  fills  the  canal.  Thespherical  mass  has  a  smooth,  polished 
surface  rather  closely  beset  with  spike-like  projections  which  are  fitted  into 
corresponding  depressions  in  the  mucosa  (Fig.  197).  The  surface  of  the  second 
mass  is  smooth.  There  are  also  two  or  three  hard,  smooth  bodies  from  1  to  2 
mm.  in  size,  which  are  wholly  embedded  in  the  mucous  membrane. 

Microscopic  examination  shows  a  normal  mucous  membrane  excepting 
where  the  projections  noted  above  are  lodged.  Here  the  glands  are  pressed 
apart  and  the  surface  epithelium,  though  intact,  is  flattened  (see  Fig.  197). 
Apparently  these  projecting  points  were  formed  in  the  crypts. 


CHAPTER  XIII. 

PATHOLOGY. 

PERITONITIS  IN   GENERAL.     LOCALIZED   PERITONITIS.     SPREADING    OR 
GENERALIZED    PERITONITIS. 

PERITONITIS  IN  GENERAL. 

The  paramount  importance  of  peritoneal  complications  of  inflammatory 
diseases  in  the  right  iliac  fossa  has  long  been  recognized,  and  in  early  times, 
when  the  cecum  was  regarded  as  the  general  source  of  the  inflammatory  affec- 
tions of  the  region,  the  terms  p  er  i  1  y  p  hi  i  t  i  s  and  p  a  r  a  t  y  phli  t  is 
were  used  tn  designate  the  extension  of  the  infection  to  the  peritoneum  and 
neighboring  tissues.  That  the  appendix  is  the  source  of 
]i  r  a  e  I  i  <•  a  1  1  y  all  c  a  s  e  s  o  f  peritonitis  1  i  in  i  ted  to  the 
c  e  e  a  1  res  i  0  n,  and  is  t  h  e  C  h  i  e  f  S  0  u  r  c  e  of  g  e  n  e  r  a  I  - 
ized  peritonitis,  is  now  universally  acknowledged.  Some  well-known 
writers  still  hold  that  perforation  of  the  cecum  with  ensuing  peritonitis  may 
result  from  the  rupture  of  a  deep-seated  stercoral  ulcer;  hut  the  majority  of 
writers  of  the  present  day,  including  Deavbr,  Lenzmann,  and  SAHLI,  are 
inclined  tn  doubt  its  occurrence,  or  to  regard  it  as  very  exceptional.  Dearer, 
as  a  result  of  his  wide  experience,  remarks  "that  stercoral  typhlitis  may  occur, 
I  will  not  deny;  that  it  dues  occur,  I  do  not  believe." 

The  presence  of  a  perforation  in  the  cecum  is  sometimes  regarded  as  a  proof 
of  the  occurrence  of  perforative  stercoral  typhlitis,  the  observers  not  bearing 
in  mind  the  fact  recognized  by  BtlRNE  in  1839  that  the  rupture  into  the  cecum 
of  an  abscess  originating  from  without,  is  a  common  event.  In  cases  where 
the  appendix  itself  is  hut  slightly  altered,  it  is  sometimes  difficult  to  determine 
in  which  direction  the  rupture  had  taken  place.  As  a  rule,  however,  the  cecum 
presents  definite  evidence  of  the  external  origin  of  the  lesion,  in  that  its  outer 
coats  show  an  extensive  defect  with  necrotic  margin  surrounded  by  inflamma- 
tory tissue;  the  opening  in  the  mucosa  is  smaller  and  the  surrounding  mucous 
membrane  smooth  and  practically  normal.  It  cannot  he  denied,  however, 
that  in  exceptional  instances  a  primary  non-specific  typhlitis 
may  occur,  and  may  give  rise  to  an  infection  of  the  surrounding  tissues  and  to 
general  peritonitis,  Reisinger,  out  of  350  cases  of  perityphlitis  operated  on 
at  the  Krankenhause  in  Mainz  found  two  in  which  the  cecum  only  was 
diseased.  In  one  of  these  cases  it  was  filled  with  hard  fecal  masses  and 
was  perforated  in  two  places.  Autopsy  revealed  no  cause  for  this  condition. 
302 


PERITONITIS    IX    GENERAL.  .'!().'! 

Carl  Beck  describes  in  detail  a  case  originally  operated  upon  for  appen- 
dicitis, in  which  partial  gangrene  of  the  cecum  was  revealed  and  during  the 
course  of  a  laparotomy  performed  later,  the  appendix  was  found  intact.  (See 
Chap.  XXI,  p.  489.) 

Sonnenburg  describes  a  case  of  circumscribed  inflammatory  disease,  prim- 
ary in  the  cecal  walls,  not  due  to  a  specific  infection,  and  apparently  not  as- 
sociated with  a  stricture.  This  writer  suggests  the  possibility  of  there  having 
been  a  hernia  of  this  portion  of  the  bowel  into  a  peritoneal  pocket.  In  one  in- 
stance related  by  RENVERS,  cited  by  Sonnenburg,  a  pericecal  abscess  followed 
a  perforation  caused  by  the  attrition  of  a  fecal  concretion  the  size  of  a  walnut, 
which  was  lodged  in  a  pocket  in  the  cecal  wall.  This  case,  as  well  as  a  second,  in 
which  a  concretion  had  formed  with  a  gall  stone  as  a  nucleus,  belong  rather  to  the 
relatively  common  class  of  cases  in  which  perforation  of  the  cecum  is  (hie  to 
injury  by  a  foreign  body.  Osler  states  that  he  has  twice  seen  perforation  of 
cecal  ulcers.  In  only  one  (Reismger)  of  the  recorded  cases  was  there  any  men- 
tion of  fecal  impaction  in  the  cecum.  The  most  convincing  proof  of  the  great 
rarity  of  this  condition  is  found  in  the  fact  that  at  autopsy  in  vivo,  and  on  the 
pi  ist  mortem  table,  fecal  stagnation  in  the  cecum  is  almost  never  observed.  That 
there  are  instances  of  typhlitis  which  go  on  to  ulceration,  and  may  lead  to  rup- 
ture with  subsequent  abscess  formation  or  diffuse  peritonitis,  is  very  true,  but 
these  are  practically  all  cases  of  secondary  disease  of  the  cecum  due  to  stricture, 
etc.,  or  else  are  cases  of  specific  inflammatory  disease,  such  as  may  affect  any 
portion  of  the  alimentary  canal.  Tuberculosis,  t  y  p  h  o  id  fever, 
a  c  t  i  n  o  mycosis,  and  a  m  ce  b  i  c  dysente  r  y  ,  all  give  rise  to 
inflammation  attended  with  ulceration,  which  may  proceed  to  perforation, 
with  all  its  unfortunate  sequelae.  Tubercular  infection  is  especially  prone  to 
become  localized  in  the  cecal  region,  and  instances  of  perforation  of  tubercular 
ulcers  are  not  rare. 

Before  considering  the  lesions  of  the  peritoneum  and  contiguous  tissues  pro- 
duced by  appendicitis,  a  brief  review  of  the  minute  anatomy  and  physiology 
of  the  peritoneum  will  aid  in  a  clearer  conception  of  the  changes  which  it  under- 
goes when  endeavoring  to  limit  or  destroy  any  irritant  to  which  it  is  subjected. 

The  topographical  anatomy  of  the  peritoneum,  with  regard  to  the  cecal  and 
neighboring  regions,  is  fully  demonstrated  in  Chap.  V.  For  the  views  expressed 
here  regarding  its  structure  and  function  I  am  chiefly  indebted  to  Lennander's 
admirable  summary  of  the  most  recent  investigations  in  this  field.  The  sur- 
face of  the  peritoneum  is  covered  with  a  single  layer  of  flattomcd  endothelial 
or  epithelial  cells.  The  margins  of  these  cells  adjoin  one  another,  and  are 
united  by  protoplasmic  processes;  thus,  when  the  cell  protoplasm  is  contracted, 
an  inter-endothelial  space  is  formed  which  is  larger  or  smaller  according  to  the 
degree  of  contraction.  The  protoplasmic  processes  at  the  same  time  undergo 
definite  lengthening  or  shortening.  This  arrangement  is  well  adapted  to  the 
variations  requisite  in  the  different  conditions  of  collapse  or  distention  of  the 


304  PATHOLOGY. 

stomach  and  intestine.  In  the  inter-endothelial  spaces  are  the  stomata  vera 
ami  stomata  spuria.  The  latter  appear  as  larger  or  smaller  points  between  the 
adjacent  cells  and  are  usually  occupied  by  leucocytes  which  have  been  taken 
up  in  passing  to  and  from  the  peritoneal  cavity.  The  stomata  vera  are  found 
at  points  where  three  or  more  cells  meet,  and  are  often  lined  with  young  endo- 
thelial cells  showing  active  nuclear  division.  They  may  appear  open  or  closed, 
apparently  according  to  the  state  of  contraction  of  the  neighboring  cells.  They 
are  distributed  generally  throughout  the  peritoneal  cavity,  but  vary  in  number 
in  different  areas,  being  most  abundant  and  largest  in  the  centrum  tendineum 
of  the  diaphragm,  then  in  the  gastro-hepatic  and  gastro-splenic  ligaments,  next 
in  the  omentum  near  the  colon,  but  relatively  few  in  the  flanks.  They  are  also 
numerous  in  the  ligaments  lata  and  in  the  mesorectum.  In  the  centrum  tendi- 
neum, experiments  seem  to  show  that  the  stomata  vera  are  continuous  withendo- 
thelial-lined  lymph  channels  which  open  directly  into  the  lymph  capillaries  and  are 
in  close  communication  with  the  lymph  channels  of  the  diaphragmatic  pleura. 

The  subserosa  consists  of  connective  tissue  rich  in  elastic  fibres,  which,  in 
some  areas,  contains  a  variable  amount  of  fat.  Under  the  endothelial  cells  of 
the  serosa  lie  the  lymph  spaces,  their  ramifications  surrounding  the  cells.  The 
larger  spare-  are  lined  with  endothelium  and  go  directly  into  the  lymph  capil- 
laries. The  abdominal  cavity  is  very  rich  in  blood  and  lymph  vessels,  and  these 
are  surrounded  with  a  network  of  endothelial-lined  lymph  spaces.  Lymph 
capillaries  are  especially  abundant  in  the  central  tendon  of  the  diaphragm. 

The  abdominal  cavity  may  be  regarded  as  a  large  lymph  sac  which  is  con- 
nected through  the  lymph  spaces  with  the  arteries  on  the  one  hand,  and  with 
the  veins  and  lymph  vessels  on  the  other.  In  the  normal  state  the  inflow  and 
outflow  are  so  regulated  that  while  the  endothelial  surface  i<  continually  moist, 
there  is  a  scarcely  measurable  amount  of  free  fluid  in  the  peritoneal  cavity. 

The  great  power  of  absorption  has  been  clearly  shown  by  experiments.  In 
a  dog  or  rabbit  a  collection  of  fluid  equal  to  10  per  cent,  of  the  body-weight  can 
be  absorbed  in  thirty  minutes.  In  the  same  animals  just  alter  death  0  percent. 
of  the  body-weight  can  be  absorbed  in  the  same  time,  hut  as  the  circulation  has 
then  ceased  the  absorbed  fluid  remains  in  the  lymph  spaces  in  the  subserosa.  The 
power  of  absorption  increases  to  a  certain  degree  with  the  increase  of  intra- 
peritoneal pressure,  but  if  the  pressure  becomes  still  greater  the  veins  and  lymph 
vessels  are  compressed  and  absorption  diminishes.  The  absorption  is  greatest 
in  the  centrum  tendineum.  Fluid  injected  into  the  abdominal  cavity  of  an 
animal  which  is  in  such  a  position  that  the  lower  part  of  the  body  is  elevated 
and  the  fluid  comes  in  contact  with  the  diaphragm,  is  absorbed  much  more 
quickly  than  wdien  the  animal  is  in  another  position.  Blood  corpuscles,  bac- 
teria, etc.,  are  also  taken  up  from  the  abdominal  cavity  in  a  very  short  time. 
After  an  injection  of  Berlin  blue  into  the  abdominal  cavity  the  colored  granules 
are  found  to  have  passed  through  the  abdominal  cavity  and  lymph  spaces  of 
the  diaphragm,  and  in  a  short  time  are  found  in  the  thoracic  duct. 


PERITONITIS    IX    GENERAL.  :!().") 

In  the  absorption  from  the  abdominal  cavity  the  chief  factors  seem  to  be  the 
inter-endothelial  spaces  and  the  stomata.     The  absorption  of  colored  granules 

appears  to  take  place  exclusively  by  this  means,  and  it   is  probable  that  l 
teria  are  taken  up  in  the  same  way. 

The  subserous  tissue  is  very  rich  in  nerves,  the  blood-vessels  especially  being 
abundantly  surrounded  in  their  finest  ramifications  by  sympathetic  nerve 
plexuses. 

In  experiments  concerning  the  sensibility  of  the  abdominal  cavity  it  has 
been  shown  that  the  normal  serosa  is  not  sensitive  to  touch  nor  to  injury,  but 
the  diseased  serosa  is  exceedingly  so.  On  testing  the  sensibility  of  the  peri- 
toneum during  the  course  of  operations  under  local  anesthesia,  it  has  been  found 
that  the  parietal  peritoneum  is  exceedingly  sensitive  to  pain  impressions,  but 
that  the  viscera,  the  omentum,  and  the  mesentery  do  not  possess  pain  nerves. 
The  pain  nerves  in  the  parietal  peritoneum  are  derived  from  the  intercostal, 
lumbar,  and  sacral  nerves,  and  course  in  the  subserosa.  It  is  very  probable 
that  painful  impressions  in  the  abdomen  are  largely  due  to  traction  upon  the 
nerves  in  the  subserosa  of  the  abdominal  parietes.  It  is  especially  noteworthy 
that  very  slight  traction  produces  pain. 

In  the  vast  majority  of  all  cases  of  appendicitis  there  is  involvement  of  the 
peritoneum.  In  chronic  appendicitis  there  are  usually  adhesions,  indicating  a 
former  acute  or  chronic  inflammatory  process.  In  acute  inflammation  all 
grades  of  peritonitis  are  seen,  from  the  mildest,  in  which  the  serosa  of  the  appen- 
dix alone  is  reddened  and  turbid,  but  without  appreciable  exudate,  to  the  most 
intense  reaction,  characterized  by  an  abundant  purulent  exudate  tilling  all  parts 
of  the  peritonea]  cavity  and  walled  off  partially,  or  not  at  all,  by  friable  adhe- 
sions into  pockets.  Between  these  extremes  all  grades  of  the  affection  may 
exist.  It  cannot  be  considered,  however,  that  the  various  forms  of  peritonitis 
merely  represent  different  stages  in  the  same  process  and  that  unless  interrupted 
by  operations  or  limited  by  the  resistance  of  the  organism,  each  individual  case 
would  proceed  through  all  stages.  On  the  contrary,  there  are  some  cases  which 
run  their  course  to  a  lethal  termination,  and  show  only  a  fibrinous  deposit 
throughout,  while  in  other  cases  there  is  from  the  outset  a  copious  purulent 
exudate.  As  a  rule,  however,  an  early  reaction  accompanied  with  a  sero- 
fibrinous exudate  precedes  the  suppurative  process. 

Animal  experimentation  has  shown  that  after  the  injection  into  the  peri- 
toneal cavity  of  a  large  amount  of  infected  material  of  a  low  grade  of  virulence, 
the  bacteria  become  absorbed  and  the  animal  lives,  while  the  same  amount  of 
material  of  a  high  virulence  causes  death  in  from  ten  to  twenty  hours,  with 
almost  no  evidence  of  peritoneal  reaction,  as  the  organism  is  overwhelmed  by 
the  rapid  absorption  of  a  large  amount  of  toxic  material.  A  small  amount  of 
unusual  virulence  causes  death  from  toxemia  with  or  without  bacteriemia.  A 
greater  dilution  of  the  same,  in  consequence  of  slower  absorption,  i~  more  favor- 
able. Likewise,  other  things  being  equal,  a  large  serous  or  purulent  exudate  is 
20 


306  PATHOLOGY. 

favorable.  The  outpouring  of  an  abundanl  exudate  is  a  distinctly  conservative 
process,  as  it  serves  not  only  to  dilute  the  infective  material,  bul  has  also  marked 
bactericidal  powers.  While,  as  stated  above,  the  normal  peritoneal  fluid  is 
bactericidal,  this  property  is  greatly  enhanced  by  the  addition  of  substances 
derived  from  disintegrated  leucocytes,  and  at  the  same  time  the  normal  phago- 
cytes also  assist  in  disposing  of  the  infection.  BuCHNEP  (cited  by  I.onzmann) 
found  that   the  alexins  contained  in  the  leucocytes  possess  a  proteolytic  power 

capable  of  destroying  albuminous  substances  and  bacteria. 

In  the  slighi  local  reaction  accompanying  mild  attacks  of  appendicitis,  and 

in  more  serious  infections  during  the  early  peritoneal  reaction  characterized 
by  a  sligh!  sero-fibrinous  exudate,  the  peritonitis  is  now  generally  believed  to 

lie  due  to  the  diffusible  toxins  produced  by  the  bacteria  and  is  of  a  chemical 
nature.  It  is  to  this  "toxic  peritonitis"  that  a  localization  of  an  infection  is 
due. 

The  varieties  of  peritoneal  infection  are  differentiated  according  to  the  amount 

and  character  of  the  exudate,  and  are  as  follows: 

Acute  fibrinous  peritonitis. 

sero-fibrinous  peritonitis. 
"      fibrino-purulent  peritonitis. 
"      purulent  peritonitis. 

"      dry  or  septic  peritonitis. 

The  various  types  of  peritonitis  appeal-  to  depend  partly  upon  the  variety 
of  the  micro-organism  concerned,  partly  upon  the  amount  and  virulence  of  the 
infection,  and  partly  upon  the  local  and  general  resistance  of  the  individual. 
By  far  the  most  important  factor  is  the  amount  and  virulence  of  the  infective 
material. 

The  extension  of  the  inflammatory  reaction  in  appendicitis  beyond  the 
organ  itself,  may  be  conveniently  considered  under  the  following  divisions: 

1.  Circumscribed  inflammation  of  the  peritoneum  and  other  structures  in 
the  immediate  neighborhood  of  the  appendix;  and  intra-  and  extra-peritoneal 
abscesses  by  direct  propagation,  including  pelvic  abscesses,  subphrenic  abscesses, 
empyema  of  the  pleural  cavity,  abscess  in  the  muscles  of  the  abdomen  and  back. 

2.  Diffuse  ami   generalized   peritonitis. 

3.  Extension  of  infection  by  way  of  the  blood  vascular  system:  thrombosis, 
purulent  phlebitis,  embolism,  liver  and  lung  abscess. 

4.  Lymphangitis,  septicemia. 


LOCALIZED   PERITONITIS. 

As  stated  above,  the   peritoneal   investment  of  the  appendix,  which  is  an 

integral  part  of  the  organ  itself,  is  involved  in  practically  all  cases  of  appendicitis, 

excepting  instances  of  mild  catarrhal  affections.     In  most  instances  the  process 

extends  beyond  this  point,  and  involves  to  a  greater  or  less  degree  the  surround- 


LOCALIZED    PERITONITIS.  307 

ing  structures.  When  operating  during  the  first  twenty-four  or  thirty-six  hours 
of  an  acute  attack,  it  is  common  to  find  a  slight  excess  of  serous  fluid  in  the  right 
iliac  fossa  with  a  little  plastic  lymph  deposited  upon  the  appendix  and  upon 
the  contiguous  visceral  or  parietal  peritoneum  forming  an  easily  separated  ad- 
hesion, while  the  surrounding  peritoneum  is  reddened  and  may  have  partly  losl 
its  normal  lustre;  or.  even  when  no  exudate  is  visible,  on  lifting  up  the  appendix 
it  may  seem  to  be  slightly  adherent  to  the  adjacent  peritoneum  and  a  somewhat 
viscid  condition  of  the  surface  is  discernible.  This  slight  local  reaction,  as  has 
been  said,  is  not  due  to  bacterial  invasion,  but  is  produced  by  the  action  of  the 
diffusible  toxins  of  the  infective  agent.  Cultures  from  the  affected  area  of  perito- 
neum, as  a  rule,  are  sterile  in  these  cases,  and  no  organisms  are  found  in  coverslip 
preparations.  In  mild  affections  of  the  appendix  the  peritoneal  reaction  may 
not  progress  beyond  this  stage,  and  resolution  soon  follows.  In  other  instances, 
however,  this  condition  only  marks  the  initial  stage  of  the  peritoneal  involve- 
ment and  is  succeeded  by  the  more  intense  reaction  which  accompanies  the 
invasion  of  bacteria.  When  the  infective  material  is  of  a  low  degree  of  viru- 
lence the  reaction  of  the  peritoneum  is  characterized  by  a  more  or  less  abundant 
fibrinous  or  sero-fibrinous  exudate,  forming  somewhat  dense,  but  at  the  outset 
very  friable  adhesions.  The  appendix  is  often  entirely  buried  in  the  thick  mass 
of  friable,  fibrinous  material,  which  glues  together  all  the  adjoining  structures. 
This  inflammatory  mass,  including  the  appendix,  is  often  very  edematous,  and 
hemorrhages  from  the  greatly  dilated  blood-vessels  frequently  occur.  In  some 
instances  the  exudate  is  so  abundant  and  increases  so  rapidly  that  an  abscess 
is  suspected.  At  an  early  date  the  invading  bacteria  are  destroyed  and  begin- 
ning organization  is  found,  which,  unless  some  untoward  accident  occurs,  pro- 
ceeds rapidly,  so  that  in  a  short  time  the  mass  becomes  greatly  diminished  in 
size,  and  finally  all  that  remains  are  the  adhesions  binding  down  the  more  or 
less  thickened  appendix.  On  examining  such  a  specimen  after  removal,  it  is 
not  uncommon  to  find  that  a  deep-seated  ulcer  or  area  of  necrosis  had  caused  a 
virtual  perforation  of  the  appendix  wall,  but  that  the  thick  adventitious  layer 
had  acted  as  a  barrier  to  the  further  progress  of  the  infection.  Very  frequently 
only  a  small  portion  of  the  serosa  of  the  appendix  and  a  correspondingly  limited 
area  of  the  adjacent  peritoneum  are  affected,  while  the  rest  of  the  appendix  is 
practically  normal.  The  distal  end  is  most  often  involved,  doubtless  on  account 
of  more  defective  drainage,  and  the  tendency  of  foreign  bodies  and  enteroliths 
to  lodge  here,  so  favoring  more  extensive  erosions  and  suppuration,  which  per- 
mit the  easy  penetration  of  the  infective  agents  to  the  surface.  When  the  first 
effort  of  nature  to  limit  the  progress  of  the  disease  is  not  successful,  the  point 
of  greatest  danger,  where  rupture  is  mosl  imminent,  fortunately  tends  to  attach 
itself  to  a  neighboring  structure  and  thus  avert  the  danger  of  a  general  peri- 
toneal infection.  The  area  of  impending  perforation  often  become-  adherent 
to  some  portion  of  the  intestinal  canal,  and  if  drainage  is  established,  a  spon- 
taneous cure  of  the  attack  mav  be  obtained.     It  is  less  fortunate  for  the  indi- 


:;n.s 


P  \  TIHllMCi  . 


vidua!  when  the  appendix  drains  into  some  other  hollow  viscus,  as  the  bladder,  the 
ureter,  the  gall  bladder,  or  the  pleural  cavity.  One  of  the  most  striking  examples 
of  nature's  ability  to  limil  disease  with  the  most  excellent  results,  is  seen  in  the 
often  observed  tendency  of  the  omentum  to  gravitate  to  the  danger  point.  A 
very  small  area  may  become  attached,  as  in  the  ease  shown  in  Fig.  198,  or  the 
tip,  a  hall',  or  even  the  entire  appendix  may  he  rolled  up  in  the  omentum  (see 
Fig.  199).  As  this  tissue  becomes  more  or  less  infiltrated  and  edematous,  a 
large  oval  mass  the  size  dl'  a  list  may  he  formed.     This  is  often  quite  movable, 

anil  on  accounl  of  the  density,  size,  and  mobility 
of  the  mass,  the  physical  signs  in  such  a  ease  are 
often  suggestive  of  a  neoplasm.  When  the  mass 
is  adherent  abscess  formation  is  closely  simu- 
lated. 

In  examining  many  specimens  consisting  of  the 
appendix  embedded  in  the  omentum,  or  with  a 
portion  of  the  omentum  attached  in  it,  I  have 
found  that  as  a  rule  there  is  a  distinct  defect  in 
the  wall  of  the  appendix  at  one  or  more  points, 
ami  that    these  areas  have  been  sealed  over  by  the 

omentum,  the  destroyed  area  being  replaced  by 

inflammatory  products.  In  the  case  shown  in 
Fig.  199  the  longitudinal  section  of  the  appendix 
shows  a  sudden  cessation  of  the  normal  coats  at  a 
point  about  2  cm.  from  the  tip,  where  for  a  dis- 
tance of  about  1  cm.  the  walls  consist  of  connec- 
tive tissue  continuous  with  the  fibrous  stroma  of 
the  omentum.  At  these  points  it  is  impossible  to 
separate  the  omentum  without  tearing  the  tissue, 
while  in  other  parts  the  appendix  may,  as  usual,  be 
peeled  quite  easily  out  of  its  bed  of  omentum.  In 
specimens  removed  during  an  acute  attack,  the 
omentum  is  found  to  be  exceedingly  hyperemic, 
and  there  is  usually  more  or  less  extravasation 
of  blood  into  the  tissue.  Purulent  foci  may  be 
found  here  and  there,  and  in  the  vicinity  of  the 
most  densely  adherent  areas,  considerable  necrosis 
may  be  present.  Under  the  microscope  a  general  edematous  and  leucocytic 
infiltration  is  found. 

In  the  peritoneal  reaction  which  is  excited  by  a  mild  irritant,  an  increased 
transudation  of  serous  fluid  accompanies  the  fibrinous  exudate,  and  may  be 
the  only  evidence  of  the  peritoneal  reaction.  This  appears  chiefly  as  an  excess 
of  fluid  collected  in  the  dependent  portions  of  the  fossa1  of  the  ileocecal  region 
and  in  the  pelvis.     At  other  times  the  fibrinous  exudate  is  permeated  with 


Fig.  198. — Acutely  Inflamed  Ap- 
pendix won  the  Omentum 
Vdherent  to  a  Point  of 
Threatened  Perforation. 

(Spj  i  i  mi  \    I  I  '  im   'I     s    t  I  I.LEV.) 


LOCALIZED    PERITONITIS. 


309 


serous  fluid  and  appears  as  a  thick,  watery,  translucent  membrane  which  is 
exceedingly  soft  and  friable.  Sometimes  the  serum  is  pocketed  in  the  midst  of 
the  fibrinous  exudate,  and  as  the  adhesions  become  organized,  the  surface  of 
the  appendix  and  the  surrounding  peritoneum  may  be  studded  with  minute, 
clear,  transparent  blebs,  varying  in  size  from  a  pin-head  to  a  split  pea,  while 
now  and  then  cysts  of  considerable  size  are  formed,  in  some  instances  inclosing 


Fig.   199. — Appendix  Rolled  dp  i\  Ohentdu. 

The  proximal  portion  has  been  stripped  out  between  the  submucous  and  internal  muscular  layers.      In  the  sec- 
tioned specimen  :i  defect  in  the  appen<lical  wall  has  been  replaced  by  granulation  tissue.     (Surg.  No.,  13141.) 


a  part  of,  or  even  the  whole  appendix.  Fig-  200  shows  an  appendix  with  a 
peritoneal  cyst  attached  to  its  tip.  observed  at  autopsy  in  a  woman  dead  of  an 
intercurrent  disease.  The  appendix  extended  directly  toward  tin1  vertebral 
column,  and  was  adherent  in  its  distal  portion.  Attached  to  the  tip  was  a 
transparent  cyst  the  size  of  an  apricot,  containing  perfectly  clear,  yellow  fluid. 
The  tip  of  the  appendix  was  thickened,  fibrous,  and  obliterated,  and  projected 


310 


PATHOLOGY. 


P"ig.    200. — Encysted    Peritonitis    Surrounding    the    Tip    of    the    Appendix. 


LOCALIZED    PERITONITIS. 


311 


Tub    nod. 


Ida,  ftor*.      / 


Fig.  201.— Encysted  Peritonitis  op  Ti  berci  lab  Origin. 

The  tip  of  the  appendix  doubled  upon  itself  uiul  held  i"  this  position  by  adhesions. 


312  PATHOLOGY. 

a  little  way  into  the  cyst.  The  specimen  shown  in  Fig.  201  was  also  observed 
at  autopsy.  In  this  case  the  cyst  which  encloses  the  entire  appendix  was  not 
due  id  disease  of  that  organ,  bul  was  part  of  a  generalized  peritonitis  of  tuber- 
cular origin.  A  sero-fibrinous  peritonitis,  as  a  rule,  is  found  only  in  cases  of 
non- perforative  appendicitis.  hut  may  sometimes  be  present  in  cases  where 
there  is  a  pin-hole  perforation. 

Histological    E  \  a  m  inat io  n. — Histological   examination  of   the 

peril al  changes  at  the  outset  shows  dilatation  of  the  blood-vessels,  swelling 

and  proliferation  of  the  endothelial  cells,  and  edema  of  the  subserosa,  with 
swelling  of  the  connective  tissue  cells  and  more  or  less  leucocytic  infiltration. 
On  the  surface  there  is  a  slight  fibrinous  deposit  mingled  with  occasional  leuco- 
cytes. As  the  infection  continues  there  is  some  degeneration  with  exfoliation 
oi  endothelium  and  more  abundant  deposit  of  fibrin  and  leucocytes.  Extrav- 
asations of  blood  both  into  the  subserous  tissue  and  upon  the  surface  are  com- 
mon and  may  he  extensive.  Very  soon  the  endothelium  along  the  margins 
of  the  denuded  areas  as  well  as  the  connective  tissue  present  evidence  of  rapid 
proliferation,  newly  formed  blood  capillaries  extend  into  the  fibrinous  deposit, 
and  the  cellular  infiltration,  which  at  first  consisted  of  polymorpho-nuclear 
leucocytes,  contains  an  increasing  proportion  of  small  round,  and  plasma  cells. 
Organization  and  cicatrization  then  proceed  more  or  less  rapidly.  As  organiza- 
tion becomes  complete,  portions  of  the  serous  surface  may  he  enclosed  by  the 
adhesions.  The  endothelial  lining  of  the  enclosed  area  then  gradually  extends 
around  the  adjacent  surface  of  the  adhesions,  forming  an  endothelial-lined  sac 
which  finally  becomes  distended  with  serous  fluid  and  forms  the  transparent 
peritoneal  cysts. 

Peri-appendical  Abscess. — The  most  frequent  and  most  important  com- 
plication of  appendicitis  is  the  occurrence  of  circumscribed  purulent  peritonitis 
and  suppuration  in  the  contiguous  retro-peritoneal  tissue.  This  accident  may 
happen  in  the  presence  or  absence  of  perforation,  hut  is  most  frequently 
associated  with  perforation  or  with  gangrene.  The  migration  of  bacteria  from 
the  lumen  of  the  appendix,  either  by  penetration  of  the  appendix  walls  or  by 
means  of  a  perforation,  is  essential  to  the  production  of  a  suppurative  peri-appen- 
dicitis. The  chief  factors  concerned  in  encapsulating  the  purulent  exudate  and 
preventing  its  general  distribution  are  the  presence  of  old  adhesions,  or  the 
occurrence  of  a  plastic  exudate,  which  precedes  the  suppurative  process  and 
serves  to  glue  together  the  neighboring  intestinal  ceils,  thus  forming  a  more  or 
less  perfect  barrier  to  the  further  extension  of  the  infection.  The  slight  inflam- 
matory reaction  which  produces  the  viscid  fibrinous  exudate,  has  already  been 
noted  as  occurring  in  the  early  stage  of  acute  appendicitis,  and,  excepting  in 
some  cases  of  very  early  perforation  or  rapid  gangrene,  usually  precedes  the 
penetration  of  micro-organisms  through  the  walls.  The  pre-perforative  stage 
of  deep-seated  ulcers  also  is  marked  by  a  local  peritoneal  reaction  which  may 
cause  protective  adhesions  to  form  before  the  floor  of  the  ulcer  gives  way.     In 


SUPPURATIVE    PERI-APPENDICITIS.  313 

Bome  cases  the  dangerous  area  may  in  this  manner  be  effectually  sealed  over,  but 
when  this  barrier  is  slight  it  is  gradually  penetrated  by  micro-organisms  which 
excite  a  purulent  reaction.     Fortunately,  as  the  suppurative  process  advances, 

the  reaction  on  the  part  of  the  tissue  which  produces  the  purulent  exudate  also 
tends  to  form  a  limiting  wall.  At  the  outset  this  consists  of  a  plastic  fibrinous 
material  of  variable  thickness.  If  the  infective  material  is  of  high  grade  of 
virulence,  or  if  a  large  amount  of  it  is  poured  out,  this  barrier  often  gives  way, 
but  in  the  majority  of  cases  it  resists  the  first  onset,  increase-  in  thickness,  and 
undergoes  speedy  organization  so  that  in  a  short  time  there  is  a  firm  dense  pro- 
tective wall  of  organizing  tissue.  In  favorable  cases,  while  the  activity  of 
the  pyogenic  organisms  causes  degeneration  ami  liquefaction  of  the  inner  coats, 
in  the  peripheral  layers,  there  is  an  active,  productive,  inflammatory  process 
which  out-balances  the  degenerative  process  in  the  interior. 

The  position  of  a  circumscribed  appendical  abscess  depends  chiefly  upon  the 
position  of  the  cecum,  the  direction  and  length  of  the  appendix,  and  the 
location  of  a  perforation,  but  it  is  influenced  by  gravity,  and  by  the  resistance 
of  the  surrounding  structures.  The  wide  range  of  the  location  of  the  abscess 
is  graphically  represented  in  Chap.  XXYI.  Naturally,  the  commonest  site 
is  in  the  right  iliac  region,  and  next  in  order  of  frequency  is  the  pelvis.  The 
frequent  occurrence  of  pelvic  suppuration  in  cases  in  which  the  appendix  does 
not  descend  in  this  direction  and  has  no  apparent  connection  with  the  abscess, 
has  been  pointed  out  in  Chap.  X.  The  right  iliac  abscess  is  usually  below  and 
exterior  to  the  cecum,  but  may  be  medianward,  anterior  or  posterior.  It  is  usu- 
ally at  some  point  in  direct  relation  with  the  abdominal  wall  ami  is  immovable. 
In  one  group  of  cases,  however,  the  abscess  may  be  more  or  less  movable  within 
the  abdominal  cavity.  These  develop  in  the  midst  of  intestinal  loops  or  be- 
tween the  two  layers  of  the  mesentery,  or  between  the  intestine  and  the  omen- 
tum (an  excellent  example  is  shown  by  Sonnenburg,  see  Plate  III  ,  or,  again, 
a  small  focus  of  suppuration  may  be  embedded  within  the  omentum,  which  is 
wrapped  around  the  appendix.  The  most  favorable  locations  as  regards  the 
general  health  of  the  patient  and  from  the  therapeutic  standpoint  are  the  pelvis 
and  flanks.  In  these  regions  there  is  less  danger  of  septic  absorption,  owing  to 
the  small  number  of  stomata  and  the  relatively  peer  lymphatic  circulation.  A 
large  abscess  in  the  flank,  however,  which  extends  upward,  may  involve  the 
subphrenic  region,  where  the  possibility  of  absorption  is  very  great.  A  sup- 
purative process  localized  amidst  coils  of  intestine,  is  especially  dangerous. 
because  of  the  ready  absorption  of  septic  material  through  the  abundant  lymph- 
atic supply  of  this  region  and  on  account  of  the  extensive  involvement  of  the 
intestinal  coils,  with  the  added  danger  of  toxemia  from  absorption  oj  intestinal 
bacteria  or  of  their  products. 

Surgical  intervention  shows  the  mosl  satisfactory  results  when  undertaken 
at  the  stage  where  the  suppurative  process  is  definitely  localized  by  a  firm  wall 
of  orcanizinfr  tissue,  and  on  this  account  many  surgeons  advocate  delay  until 


.",1  1  PATHOLOGY. 

this  "  w  ailing  off"  process  is  well  established.  Unfortunately,  there  are 
several  factors  to  be  reckoned  with,  which  materially  diminish  the  benefits  to 
be  gained  from  this  expectant  method  of  treatment. 

1.  The  abscess  wall  may  be  imperfect  at  one  or  more  points  and  gradually 
give  way,  forming  secondary  abscesses  which  may  be  definitely  circumscribed, 
or  may  in  turn  proceed  to  form  other  purulent  foci,  the  progressive  fibrino-puru- 
lent  peritonitis  of  Mikulicz. 

2.  Bacteria  may  slowly  penetrate  the  apparently  intact  wall  of  the  abscess, 
and  cause  secondary  abscesses  to  form  which,  however,  do  not  communicate. 
These  cases  are  particularly  important  from  the  therapeutic  standpoint,  as  the 
operator,  finding  a  circumscribed  abscess  with  intact  walls,  may  nut  recognize 
the  presence  of  the  secondary  pockets  and  so  fail  to  evacuate  and  drain  them. 

3.  The  heightened  virulence  and  rapid  accumulation  of  fluid  may  cause 
necrosis  and  rupture  of  the  abscess  into  the  general  peritoneal  cavity  with  an  en- 
suing generalized  peritonitis;  or,  without  rupture  of  the  abscess,  -virulent  micro- 
organisms may  penetrate  its  walls,  and  induce  spreading  or  generalized  peritonitis. 

4.  The  abscess  may  rupture  in  other  unfavorable  directions,  as  into  the 
pleural  cavity  or  lungs;  into  the  gall-bladder;  into  some  portion  of  the  urinary 
tract;  or  it  may  perforate  the  fascia  transversalis  and  produce  a  wide-spread 
phlegmon  of  the  abdominal  walls.  It  may  erode  the  huge  blood-vessels,  or 
cause  septic  lymphangitis  or  phlebitis. 

5.  Profound  septicemia  may  develop. 

Retro-peritoneal  Abscess. — AVhen  the  appendix  is  situated  behind  the 
cecum  and  is  extra-peritoneal,  an  abscess  may  develop  entirely  without  the 
general  peritoneal  cavity.  Figs.  72  to  78  illustrate  the  arrangement  of  the 
peritoneum  in  these  cases.  Usually  in  such  cases  the  posterior  aspect  of 
the  cecum  also  is  devoid  of  a  peritoneal  covering  and  forms  part  of  the 
abscess  wall.  In  some  instances,  however,  the  cecum  may  be  wholly  intra- 
peritoneal, while  the  appendix  lies  behind  the  peritoneal  lining  of  the  posterior 
abdominal  wall,  in  which  case  the  cecum  may  not  be  involved  in  the  suppura- 
tive process.  More  rarely  the  appendix  is  covered  by  the  peritoneum  of  the 
posterior  surface  of  the  cecum,  and  an  abscess  may  develop  in  the  posterior  cecal 
wall,  from  there  extending  upward  into  the  abdominal  wall.  In  exceptional 
instances  extra-peritoneal  abscesses  form,  when  the  appendix  is  in  the  subcecal 
position  and  is  provided  with  the  usual  peritoneal  investment.  This  may  occur 
in  different  ways.  The  infection  may  extend  by  way  of  the  mesappendix,  either 
by  direct  propagation  from  a  purulent  focus  in  the  mesentery,  with  or  without 
perforation  of  the  appendix;  or  by  means  of  the  lymphatics.  In  other  instances 
the  appendix  has  been  connected  by  adhesions  to  the  abdominal  parietes,  in 
which  case  the  double  peritoneal  layer,  united  by  granulation  or  scar  tissue,  is 
penetrated  by  the  pyogenic  bacteria,  and  the  suppurative  process  then  continues 
extra-peritoneally.  Finally  an  intra-peritoneal  abscess  may  penetrate  the 
abdominal  fascia  and  become  extra-peritoneal. 


SUPPURATIVE    PERI-APPENDICITIS.  315 

Abscesses  developing  behind  the  peritoneum  may  infiltrate  the  surrounding 
abdominal  wall,  or  may  burrow  between  the  peritoneum  and  subjacent  mus- 
culature in  various  directions.  The  muscles  of  the  lumbar  region  arc  frequently 
involved  and  a  huge  abscess  may  form,  pointing  in  the  lumbo-sacral  region  or 
extending  along  the  ileo-psoas  muscle  to  the  thigh  or  inguinal  region.  G.  W. 
Chile,  of  Cleveland,  has  had  a  case  in  which  the  abscess  extended  from  the  right 
iliac  fossa  down  the  inner  aspect  of  the  thigh  to  the  popliteal  space, where  there 
was  a  large  collection  of  pus.  In  some  cases  the  ileo-psoas  muscle  becomes 
completely  gangrenous,  and  the  purulent  process  may  even  involve  the  peri- 
osteum of  the  lumbar  vertebrae  or  of  the  iliac  bone-. 

A  glance  at  the  anatomical  relations  of  this  part  shows  with  what  facility 
the  infection  may  extend  upward  into  the  lax  perirenal  tissue  or.  advancing 
still  further,  how  easily  a  subphrenic  abscess  may  develop  extra-peritoneally. 
As  has  been  noted  previously,  a  circumscribed  peri-appendical  abscess  of  intra- 
peritoneal origin  may  also  extend  to  the  subphrenic  region.  In  either  case  per- 
foration of  the  diaphragm  may  result  in  a  pyothorax,  or,  owing  to  the  rich  anas- 
tomoses between  the  lymphatics  of  the  abdominal  and  pleural  surfaces  of  the 
diaphragm,  a  septic  pleuritis  may  develop  in  the  absence  of  perforation.  In  4 
out  of  the  7  cases  of  subphrenic  abscess  observed  at  autopsy,  the  process  had 
extended  to  the  pleural  cavity,  but  in  none  was  there  a  perforation  of  the  dia- 
phragm. The  purulent  process  may  extend  along  to  the  course  of  the  large 
vessels  beneath  Poupart's  ligament,  and  into  the  groin.  An  apparently  rare 
condition  is  found  in  cases  of  retro-peritoneal  pelvic  abscess  (see  Chap.  XXVI). 
In  a  case  described  by  Lenzmann,  the  purulent  process  extended  behind  the 
peritoneum  to  the  splenic  region. 

The  contents  of  the  abscess  varies  in  amount  from  a  few  cubic  centimetres 
to  a  litre  or  more.  In  a  case  cited  by  Frrz  more  than  a  gallon  of  pus,  liquid 
feces,  and  scybaUe  were  removed.  An  apparently  large  abscess  may  consist 
of  a  thick  mass  of  edematous,  infiltrated  tissue,  containing  only  a  few  cubic 
centimetres  of  pus.  In  other  instances,  the  abscess  walls  are  thin  and  there  is 
relatively  a  large  amount  of  fluid. 

The  contents  are  usually  a  creamy  or  a  yellowish  purulent  fluid  of  rather  thin 
consistency,  and  having  the  characteristic  odor  of  c  o  1  o  n  bacillus  putre- 
faction. In  rare  instances  the  pus  has  ablue  color  due  to  the  presence  of  bacil- 
lus pyocyaneus.  Occasionally  the  fluid  has  an  ichorous  character.  It 
is  often  distinctly  feculent  and  of  a  brownish  color.  Particles  of  fecal  matter 
are  sometimes  found  when  the  area  of  perforation  in  the  appendix  is  large. 
"When  the  abscess  cavity  communicates  with  some  portion  of  the  intestinal 
canal,  a  large  portion  of  the  intestinal  contents  may  |>a<s  directly  into  the  ab- 
scess. An  inspissated  fecal  mass  or  a  concretion  is  found  in  the  abscess  in  a 
considerable  number  of  cases  ami  it  is  not  uncommon  to  find  the  necrotic  appen- 
dix lying  free  in  the  cavity.  Quite  frequently  there  is  evidence  of  slight  hemor- 
rhage into  the  cavity.     Ehrich  records  two  cases  in  which  there  were  large 


:;iii  PATHOLOGY. 

quantities  of  fluid,  blood,  and  clots,  evidently  due  to  erosion  of  a  large  vessel, 
although  the  exact  source  of  the  hemorrhage  was  no!  ascertained.  Upon  open- 
ing the  abscess  it  is  not  uncommon  to  find  bubbles  of  gas  escaping  with  the 
fluid  contents.  In  some  cases  this  is  due  to  the  admixture  of  air  from  the 
intestinal  canal,  and  it  is  especially  frequent  when  the  appendix  abscess  is 
associated  with  perforation  of  the  cecum.  In  other  instances  this  phenomenon 
is  due  to  the  presence  of  one  or  more  of  the  intestinal  gas-producing  micrc- 

niisnis  in  the  abscess  cavity,  and  may  exist  in  the  absence  of  perforation. 
The  bacillus  a  e  i-  o  g  e  n  es  caps  ul  a  tus  has  been  found  in  rare  cases. 

Results  of  Circumscribed  Peri-appendical  Abscess.  —The  disastrous  conse- 
quences which  may  follow  abscess  formation  have  been  enumerated  above. 
It  i<.  however,  unquestionably  true  that  a  spontaneous  cure  may  terminate  the 
attack,  leaving  in  some  instances  an  obliterated  appendix  and  immunity  from 
further  attacks;  in  other  cases,  a  deformed  appendix,  which  is  one  of  the  mosl 
important  factor-  in  causing  future  attacks;  and  in  other  cases-still,  adhesions 
remain  which  are  often  the  cause  of  chronic  digestive  disturbances  and  are  a 
source  of  danger,  in  that  they  form  constricting  hands,  beneath  which  a  loop 
of  intestine  max-  become  incarcerated. 

1!  esolution  may  he  brought  about  in  two  ways: 
namely,  by  rupture  of  the  abscess  in  a  direction  which  insures  favorable  drain- 
age, or  by  gradual  absorption  of  the  inflammatory  products.  Sahli  believes  t  hat 
drainage  is  a  much  more  important  factor  than  absorption  in  promoting  resolu- 
tion. In  either  case,  as  in  non-suppurative  forms  of  peritonitis,  the  subsidence 
of  the  inflammation  is  followed  by  the  disappearance  or  shrinkage  of  the  mass. 

A.S  the  abscess  progressively  enlarges,  the  increasing  pressure  impedes  the 
productive  inflammatory  process  in  the  periphery,  and  also  tends  to  produce 
tissue  necrosis,  until  finally  the  abscess  wall  gives  way  at  the  point  of  least  re- 
sistance. This  end  is  further  hastened  by  the  increased  activity  of  the  bacteria 
at  the  point  of  lessened  resistance.  The  abscess  may  rupture  in  such  a  direc- 
tion that  more  or  less  perfect  drainage  is  established  and  a  spontaneous  cure 
may    result. 

I!  u  p  t  u  r  e  t  h  r  o  u  ir  h  t  h  e  a  b  d  o  m  i  n  a  1  w  a  1  1.  or  into  the 
intestinal  c  a  n  a  I . — The  general  tendency  is  for  rupture  to  occur  through 
the  abdominal  wall,  or  into  some  portion  of  the  intestinal  canal.  The  relative 
frequency  with  which  the  abscess  opens  through  the  abdominal  wall,  or  into 
one  of  the  body  cavities,  is  indicated  by  the  following  statistics  collected  by 
SoNNENBl  RG   'combined  by  A.  0.  J.   KeLLI  I: 


Through  the  abdominal  wall     

40 

Into  i In-  cecum 

in 

Other  portions  of  intestinal  canal 

Peritoneal  cavity ......           

Pleural  cavity     

11 

8 

0 

Lrinarv  bladder           

. .  :! 

1 

SUPPURATIVE    PERI-APPENDICITIS.  311 

Muhsam's  statistics  also  show  that  rupture  occurs  oftenest  through  the  ab- 
dominal wall,  and  next  in  frequency  into  the  intestinal  canal,  hut  give  the  rectum 
as  the  part  of  the  intestine  most  commonly  involved.  The  third  direction  in 
order  of  frequency,  according  to  Muhsam's  statistics,  is  through  the  vagina. 
Other  writers  do  not  regard  spontaneous  rupture  through  the  vagina  as  a  fre- 
quent occurrence. 

Sonnenburg  could  find  no  reference  in  the  literature  to  perforation  of  a 
peri-appendical  ahscess  into  the  gall  bladder,  but  describes  a  case  which  came 
under  his  own  observation.  The  patient  had  had  several  perityphhtic  abscesses 
evacuated,  and  then  a  new  collection  of  pus,  which  was  connected  with  the 
original  cavity  by  a  narrow  channel,  pushed  in  between  the  mesentery  and  the 
under  surface  of  the  liver,  and  opened  into  the  gall  bladder.  The  abscess 
contained  dark,  bile-stained  pus.  Brewer  has  reported  a  case  in  which  an 
empyema  of  the  gall-bladder  occurred,  but  he  does  not  describe  a  close  con- 
nection between  the  two  cavities. 

Sonnenburg  also  describes  a  case  in  which  a  pyocele  testiculi  formed  as  a 
result  of  a  perityphhtic  abscess,  probably  owing  to  a  patent  processus  vaginalis. 
Rupture  through  the  abdominal  wall  usually  occurs  in  the  right  flank,  but  is 
sometimes  found  in  the  back,  and  is  not  infrequent  at  the  umbilicus.  In  the  lat- 
ter case  an  inflamed  ductus  omphalo-mesentericus  is  often  suspected,  the  differen- 
tial diagnosis  before  operation  being  sometimes  impossible.  Rupture  through  the 
abdominal  wall  or  into  the  intestinal  canal  is  most  favorable  for  a  spontaneous 
cure.  If  thorough  drainage  is  established,  the  cavity  is  rapidly  obliterated  by 
granulation,  and  the  opening  soon  closes.  In  a  considerable  proportion  of 
cases,  however,  a  fistula  forms  which  may  close  spontaneously  in  a  few  weeks. 
or  may  persist  indefinitely.  In  some  instances  an  apparent  cure  is  followed  by 
re-opening  of  the  sinus  and  increased  discharge,  which  may  again  disappear,  only 
to  recur.  A  fistula  following  spontaneous  rupture  of  a  peri-appendical  abscess 
may  be  simple,  in  which  case  the  discharge  is  merely  purulent ;  or  the  fistula  may 
be  fecal.  The  fistula  may  also  be  single  or  multiple.  In  one  of  Sonnenburg 's 
cases  there  were  several  sieve-like  perforations  of  the  integument.  The  persistence 
of  a  simple  fistula  is  usually  due  to  the  presence  of  some  focus  of  infection,  often 
an  enterolith  or  foreign  body,  and  after  this  comes  away  in  the  discharge,  or  is 
removed,  a  spontaneous  cure  soon  follows.  In  some  instances  the  failure 
to  close  spontaneously  seems  to  depend  upon  the  rigidity  of  the  inflammatory 
walls  of  the  sinus,  which  prevents  approximation  of  its  sides  and  delays  the 
absorption  of  the  pyogenic  lining.  A  thorough  curetting  of  the  sinus  in  such  a 
case  usually  results  in  speedy  cure.  Very  often,  after  the  spontaneous  or 
operative  opening  of  the  abscess,  a  fecal  fistula  forms,  usually  communicating 
with  the  cecum  either  at  a  point  corresponding  to  the  base  of  the  appendix, 
or  at  some  other  point  where  partial  necrosis  had  occurred  prior  to  the 
evacuation  of  the  abscess.  There  is  usually  a  single  opening  into  the 
bowel,  but  sometimes  there  are  several.     Fecal  fistulas  commonly  close  spon- 


318  PATHOLOGY. 

taneously.  The  failure  to  *  1  < >  so,  as  in  simple  fistulas,  may  generally  be  at- 
tributed to  the  presence  of  an  infective  focus  in  the  fistulous  trad  wheredrain- 
age  is  defective.  The  eversion  of  the  mucosa  into  the  channel  probably  delays 
the  approximation  of  the  margins  of  the  intestinal  defect,  but  rarely  extends 
far  enough  to  prevent  the  final  obliteration  of  the  sinus. 

The  evacuation  of  the  abscess  cavity  into  the  intestinal  canal  may  also 
result  in  complete  disappearance  of  the  perityphlic  mas-.  Such  cases  are 
too  common  to  require  enumeration.  There  is  generally  the  history  of  the 
presence  of  a  large  tumor  associated  with  the  usual  clinical  signs  of 
intra-abdominal  suppuration,  then  the  sudden  disappearance  or  diminu 
tion  of  the  mass  accompanied  by  the  passage  of  pus  per  rectum.  Fecal  concre- 
tions may  be  discharged  with  the  fluid  portions  of  the  abscess  contents  and  even 
a  part  or  the  whole  of  the  appendix,  which  has  sloughed  off  from  its  attach- 
ment, may  also  be  discharged.  Fig.  b~>()  shows  a  gangrenous  appendix  which 
was  passed  per  rectum.  In  some  cases  there  are  coincident  openings  into  the 
bowel  and  the  bladder,  and  in  a  case  described  bySEDiLLOT,  vesical,  intestinal, 
and  abdominal   listulas  had   formed. 

In  some  cases  the  evacuation  of  the  abscess  contents  is  only  partial,  and 
fecal  concretions,  foreign  bodies,  or  collections  of  infective  material  may  remain; 
and,  again,  a  wide  delect  in  the  intestinal  wall  may  form,  through  which  the 
contents  of  the  bowel  pass  into  the  abscess  cavity.  .Not  uncommonly 
an  enterolith  or  foreign  body  which  has  remained  in  the  cavity  finally  becomes 
encapsulated  in  a  dense  bed  of  adhesions.  In  one  case,  recently  observed,  a  con- 
cretion was  found  embedded  in  the  muscular  coat  of  the  transverse  colon  a 
short  distance  from  the  tip  of  the  retrocecal  appendix.  It  is  probable  that  in 
this  ease  the  abscess  had  discharged  its  contents  through  a  small  opening  in 
the  intestinal  wall  and  that  the  concretion  had  been  unable  to  pass  through. 

The  pouring  oul  of  feculent  material  from  the  intestinal  canal  into  the  abscess 
cavity  is  always  attended  with  unpleasant  and  often  disastrous  consequences. 
The  conditions  present  are  most  favorable  for  heightening  the  virulence  of  the 
contained  micro-organisms  and  septic  absorption  progresses  rapidly.  Chris- 
toffers  reported  a  case  in  which  a  perityphlitic  abscess  ruptured  into  the  rec- 
tum. The  temporary  improvement  following  this  event  was  succeeded  by  a 
rapid  return  of  the  unfavorable  symptoms.  Autopsy  showed  a  large  cloaca 
containing  fecal  material  in  Douglas'  cul-de-sac,  which  communicated  with  the 
rectum  through  two  ragged  openings.  Grawitz  has  described  a  similar  case  of 
stercoral  abscess. 

R  u  p  t  ur  e  into  the  B  1  a  d  d  e  r. — There  are  numerous  observations 
relating  to  infections  of  the  bladder  accompanying  appendicitis  and  a  few  in- 
stances of  involvement  of  the  ureter  ami  of  the  pelvis  of  the  kidney.  The  toxic 
and  infective  lesions  of  the  kidney,  consisting  usually  of  an  acute  parenchy- 
matous nephritis,  are  common  to  all  acute  infections,  and  present  nothing  pecu- 
liar in  their  association  with  disease  of  the  appendix.     A  purulent  cystitis,  or  a 


.SUPPURATIVE    PERI- APPENDICITIS.  319 

ureteritis  with  ascending  pyelonephritis,  may  be  produced  by  the  direct  penetra- 
tion of  the  bladder  or  ureteral  walls  by  infective  micro-organisms  from  a  sur- 
rounding inflammatory  mass.  In  other  cases  the  bladder  wall  is  perforated,  and 
the  appendix  or  a  peri-appendical  abscess  drains  directly  into  the  bladder.  A 
true  vesico-appendical  fistula  is  comparatively  rare,  but  the  rupture  of  a  pelvic 
abscess  of  appendical  origin  into  the  bladder  is  nut  uncommon.  Keen,  describ- 
ing an  instance  of  the  former  condition  in  1S98,  could  not  find  a  similar  case  in  the 
literature,  but  commented  upon  the  well-known  occurrence  of  the  latter.  Out 
of  25  cases  of  perforation  of  the  bladder  collected  by  Appuhn,  in  4  cases  only 
was  there  a  direct  communication  established  between  the  appendix  and  the 
bladder.  In  many  cases  of  appendical  abscess,  the  suppurative  process  is  local- 
ized well  back  in  Douglas'  cul-de-sac  and  the  bladder  is  not  affected.  In  other 
ca<(-<,  however,  the  lateral  fomices  and  the  space  of  Retzius  are  involved,  the 
bladder  then  forming  part  of  the  abscess  wall.  As  the  pressure  within  the 
abscess  increases,  the  portion  of  its  wall  which  is  least  resistant  gradually  gives 
way,  and  finally  rupture  occurs,  sometimes  into  the  bladder,  sometimes  into  the 
rectum,  or  even  in  both  directions.  As  a  rule,  an  acute  cystitis  precedes  the 
rupture  of  the  bladder  wall,  but  in  a  few  instances  the  mucous  membrane  has 
remained  perfectly  smooth  and  normal  even  while  a  large  abscess  has  been 
draining  into  the  bladder.  In  a  case  described  by  Halle  an  acute  vegetative 
cystitis,  associated  with  severe  hematuria  and  the  presence  of  a  perivesical 
mass,  led  to  the  diagnosis  of  a  new  growth  of  the  bladder  wall.  In  this  case 
two  minute  perforations  in  the  midst  of  polypoid  outgrowths  in  the  bladder 
led  into  a  hyperplastic  inflammatory  mass  having  a  cavity  as  large  as  a  fist, 
filled  with  clotted  blood.  The  appendix  was  partly  embedded  in  the  wall  of 
the  mass.  In  some  instances  the  inflammation  of  the  bladder  wall  induces  the 
formation  of  phosphatic  calculi,  and  in  a  few  cases  extra-vesical  calculi  have 
formed  in  the  inflammatory  tissue. 

In  some  instances  the  establishment  of  drainage  by  way  of  the  bladder  has 
resulted  in  the  complete  disappearance  of  the  inflammatory  mass,  and  is  soon 
followed  by  the  spontaneous  closure  of  the  vesical  fistula.  Again,  however. 
drainage  may  not  be  efficient,  urine  may  pass  into  the  abscess  cavity,  and  the 
patient  finally  succumbs  to  the  effect  of  the  prolonged  suppuration,  or  to  peri- 
tonitis. In  some  cases  the  lumen  of  the  appendix  or  some  portion  of  the  in- 
testinal canal  may  communicate  with  the  abscess  and  a  vesicointestinal  fistula 
is  indirectly  established. 

True  vesico-appendical  fistulas,  as  already  stated,  are  rare.  The  first  essen- 
tial factor  in  their  development  is  that  the  appendix  should  become  adherent 
to  the  bladder,  which  presupposes  an  abnormally  long  appendix  in  the  pelvic 
position,  or  a  high  position  of  the  bladder.  To  the  latter  factor  may  doubt- 
less be  attributed  the  fact  that  in  four  out  of  five  cases  the  trouble  dated  from 
early  childhood.  Two  of  the  patients  were  four  years,  one  seven  years,  anil  one 
eight  years  of  age  when  the  first  evidence  of  the  trouble  appeared.     When  adhe- 


320  PATHOLOGY. 

si  mi  is  have  formed  between  the  organs,  the  further  course  of  the  process  is  readily 
understood.  The  usual  tendency  of  the  tip  to  show  themosl  pronounced  ulcera- 
tive and  gangrenous  lesions  (p.  270)  is  doubtless  increased  when  the  appendix 
is  fixed  in  this  position,  and  the  infective  process  readilj  spreads  to  the  contigu- 
ous bladder  wall.  Hut  the  mosl  important  factor  is  unquestionably  the  in- 
fluence  of  foreign  bodies.  With  the  exception  of  Appi  hn's  case  this  factor 
was  present  in  all.  In  Keen's  ease  the  patient,  when  seven  years  of  age,  was 
troubled  with  dysuria,  and  passed  a  pin  per  urethram,  probably  from  the  vermi- 
form appendix.  Kingdon's  patient,  a  boy  seven  years  old,  for  three  years  had 
had  repeated  attacks  of  dysuria,  relieved  on  each  occasion  by  the  passage  of  a 
worm  from  tin-  urethra;  in  this  ease  also  the  bladder  contained  a  calculus 
with  a  large  pin  embedded  in  its  centre.  There  were  two  fistulous  openings 
from  the  bladder  into  the  appendix  (see  Chap.  XVI,  p.  365).  In  the  case  de- 
scribed by  Krackowitzer  the  patient,  when  eight  years  old,  passed  a  living 
worm  per  urethram,  and  some  years  after  another  worm  and  some  berry  seeds. 
In  JERVALL'S  case  the  patient,  between  the  ages  of  four  and  ten  years,  had  four 
attacks  of  intestinal  inflammation  followed  by  vesical  symptom-,  and  at  one 
time  vegetable  matter  was   demonstrated    in    the  urine.      A  stercoral   calculus 

was  present  in  the  bladder.     In  all  of  these  cases  the  true  nature  of  the  trouble 

was  only  discovered  later,  at  operation  or  autopsy.  In  the  older  literal  me  there 
are  many  highly  suggestive  descriptions  of  cases  in  which  intestinal  worms, 
fecal  concretions,  ami  other  foreign  bodies  have  been  passed  by  way  of  the 
bladder,  a  vesico-intest inal  fistula  in  some  instances  persisting.  These  cases, 
however,  lacked  the  control  of  autopsy  in  VIVO,  or  postmortem  examinations. 
The  cases  in  which  the  perityphlic  abscess  ruptures  into  the  thoracic  cavity. 
involving  the  pleural  cavity,  lungs,  or  pericardium,  have  been  fully  considered  in 
the  chapter  on  autopsy.  The  event,  however,  is  not  necessarily  fatal,  as  there 
are  many  cases  recorded  in  which  recovery  has  succeeded  the  perforation  of  the 
diaphragm  and  subsequent  discharge  of  the  abscess  contents  through  an 
intercostal  space.  II.  A.  McCaLLUM  relate-  a  case  in  which  at  autopsy  upon  an 
individual,  who  sixteen  years  before  had  suffered  from  peritonitis  accompanied 
with  abscess  of  the  lung,  the  appendix  was  found  on  the  upper  surface  of  the 
liver  and  showed   trace-  of   an  old   inflammation;      There  were  also  evidences  of 

the  discharge  of  pus  through  the  eighth  intercostal  space,  and  by  the  lung. 

That  resolution  sometimes  follows  the  absorption  of  the  exudate  in  purulent 
as  well  as  non-purulent  peri-appendicitis,  is  evident  from  the  clinical  history 
and  operative  findings  in  numerous  cases. 

It  is  not  uncommon  to  find  a  definite,  large  mas-  gradually  diminish  in  the 
absence  of  any  evidence  pointing  to  a  rupture  into  the  intestine,  and  at  opera- 
tion in  the  interval,  after  the  symptoms  have  subsided,  dense  adhesions  are 
found,  embedded  in  which  there  is  an  enterolith  or  foreign  body,  indicating  that 
there  had  been  a  large  perforation  of  the  appendix  and  a  strong  probability  that 
the  original  mass  had  contained  a  purulent  focus.     In  many  instances  resolu- 


SUPPURATIVE    PERI-APPENDICITIS.  321 

timi  is  only  partial,  a  chronic  inflammation  or  a  latent  focus  of  disease  remain- 
ing indefinitely.  A  complete  cure  is  effected  when,  all  organisms  being  de- 
stroyed, the  fluid  portion  of  the  abscess  contents  first  becomes  absorbed,  then 
the  solid  constituents  become  disintegrated  and  absorbed  and  the  remaining 
organized  portions  of  the  abscess  wall  undergo  cicatrization,  so  that,  finally,  the 
only  evidence  of  the  former  mass  consists  in  more  or  less  numerous  adhesions. 
In  other  instances,  only  the  fluid  contents  arc  absorbed,  and  the  solid  portions, 
becoming  desiccated,  form  the  centre  of  a  dense  mass  of  inflammatory  products, 
llmx  observed  a  case  in  which  the  walls  of  the  abscess  had  become  calcified. 
Micro-organisms  of  low  virulence  may  also  be  present  in  a  quiescent  state  for 
months  or  years,  or,  again,  the  contents  of  the  abscess  may  be  wholly  absorbed 
with  the  exception  of  an  enterolith  or  foreign  body  which  escapes  from  the 
appendix  and  remains  a  source  of  irritation,  to  excite  a  chronic  inflammatory 
reaction.  This  reaction  sometimes  appear-  to  be  greatly  in  excess  of  the 
amount  required  for  a  simple  reparative  process.  Quite  often,  when  operat- 
ing upon  a  patient  with  a  history  of  a  tumor,  a  dense  mass  of  inflam- 
matory products  is  found,  having  as  a  nucleus  a  small  focus  of  necrotic 
substance,  or  a  foreign  body;  or  there  may  even  lie  an  empty  cavity  lined  with 
granulation  tissue.  There  are  numerous  cases  in  which  the  excessive  produc- 
tive inflammatory  process  has  led  to  the  suspicion  of  the  presence  of  a  new  growth 
("Appendicite  a  forme  neo-plasique,"  Pozzi).  The  essentially  chronic  nature  of 
the  reaction,  often  associated  with  an  insidious  onset,  is  suggestive  in  its  clinical 
features  of  a  neoplasm,  and  the  dense  solid  tumor  found  at  autopsy  apparently 
confirms  the  diagnosis,  which,  however,  the  pathological  examination  and  further 
course  of  the  disease  entirely  disprove.  The  following  cases  observed  in  the  sur- 
gical department  of  the  Johns  Hopkins  Hospital  are  interesting  examples  of  this 
condition. 

(J.  H.  H.  Surg.  Xo.  11,812.)  Male,  age  thirty.  Complaint,  tumor  and  per- 
sistent pain  in  the  right  iliac  fossa;  progressive  wasting.  Insidious  onset  three 
months  before  admission.  Xo  fever,  nausea,  nor  vomiting.  In  the  right  iliac 
region  there  was  a  slightly  irregular,  hard  mass  about  5  cm.  in  diameter.  It  was 
apparently  fixed.  At  operation,  dense  pericecal  tissue  resembling  carcinoma  was 
cut  through,  exposing  the  cecum,  the  whole  posterior  wall  of  which  was  found  in- 
durated, while  the  glands  in  the  neighboring  mesentery  were  enlarged.  As  the 
growth  was  deemed  ineradicable,  a  gland  was  removed  for  diagnostic  purposes  and 
the  abdomen  closed.  Microscopic  examination  showed  a  simple  adenitis,  and  two 
years  later  the  patient  was  enjoying  excellent  health. 

(J.  II.  II.  Surg.  Xo.  5686.)  Male,  age  nineteen.  Admitted  in  the  second  attack 
of  appendicitis;  first  attack  six  months  before,  acute,  with  abscess.  The  present 
illness  began  three  weeks  before  with  slight  pain,  associated  with  rapid  failure  of 
health.  Xo  intestinal  symptoms.  Temperature  100°  F.  The  abdominal  walls 
were  edematous  and  a  slightly  tender  mass  occupied  the  right  iliac  fossa,  extending 
beyond  the  median  line.  On  rectal  examination  a  smooth,  hard,  fixed  mass  was 
21 


;;_'_>  PATHOLOGY. 

palpated.  At  operation  the  tumor  was  found  to  consist  of  whitish-red,  dense  tissue 
surrounding  a  mass  of  necrotic  material.  A  diagnosis  of  sarcoma  was  made.  The 
cavity  was  curetted  and  drainage  inserted.  Alter  recovering  from  the  operation 
the  patient  was  sent  home  to  die.    Six  years  later  he  was  perfectly  well. 

Sonnenburg  cites  a  caseof  Schbde's,  who,  thinking  that  he  was  dealing  with 
a  carcinoma,  found  an  old  abscess  with  dense,  thick  walls,  which  still,  however, 
contained  fluid.  In  a  case  described  by  Fengeb  the  hardness  of  the  mass 
associated  with  dilatation  of  the  subcutaneous  veins  strongly  suggested  a  new- 
growth.  The  removal  of  two  stercoral  concretions  was  followed  by  the  dis- 
appearance of  the  mass.  Similar  cases  have  been  described  by  Richard, 
F  \m;r..  and  others. 

SPREADING  AND  GENERALIZED  PERITONITIS. 

By  diffuse  or  spreading  peritonitis  is  meant  that  while  the  entire  peritoneal 
cavity  is  not  involved,  the  inflammatory  process  is,  nevertheless,  not  definitely 
localized,  although  there  may  be  signs  of  an  inefficient  tendency  to  become  limited, 
and  the  reaction  is  usually  most  marked  in  the  region  of  the  appendix.  In  gener- 
alized  peritonitis  there  is  no  evidence  of  any  attempt  toward  a  limiting  process, 
and  practically  the  whole  cavity  is  involved. 

Diffuse  or  generalized  peritonitis  is  usually  regarded  as  one  of  the  more 
remote  complications  of  appendicitis,  but,  nevertheless,  is  apprehended  with 
dread  as  an  accident  liable  to  occur  without  warning  in  any  stage  of  the  disease 
and  in  cases  of  apparently  the  mildest  form  as  well  as  in  those  which  present 
the   most    severe   clinical   symptoms. 

It  is  difficult  to  estimate  its  relative  frequency,  as  hospital  statistics  for  obvious 
reasons  probably  give  too  high  a  proportion  of  cases.  However,  an  approximate 
idea  of  the  frequency  with  which  it  occurs  may  be  obtained  from  the  percentage  of 

cases  found  at  operati m  cases  of  appendicitis,  and  from  the  number  of  cases 

of  peritonitis  in  which  the  appendix  was  the  source  of  the  infect  ion,  compared  with 
the  number  having  some  other  origin. 

In  the  surgical  department  of  the  Johns  Hopkins  Hospital,  out  of  600  opera- 
tions on  cases  of  appendicitis,  diffuse  or  generalized  peritonitis  was  present  in 
61  cases,  or  10  per  cent.  There  were  104  cases  of  diffuse  peritonitis  exclusive 
of  those  following  gunshot  wounds  of  the  abdomen  and  post-operative  infec- 
tions.    In  these  cases  the  chief  sources  of  the  infection  were, — 

Appendicitis 61 

Typhoid  perforation 15 

Intestinal  neoplasms 4 

Amn  Lie  dysentery 2 

Other  causes  were  acute  intestinal  obstructi  0  a,  he  r  n  i  a  , 
volvulus,  gangrene  following  thrombosis  of  mesenteric  vessels, 
acute    cholecystitis,    etc. 


SPREADING    AND    GENERALIZED    PERITONITIS.  323 

Grawitz  found  that  in  560  cases  of  secondary  purulent  peritonitis  the  infec- 
tion originated  from, — 

Typhoid  ulceration 32  times. 

Perforated  appendix    24       " 

Tubercular  ulceration  of  intestine 19 

Ulceration  of  stomach   16       " 

Botjness  found  these  causes  in  about  the  same  relative  proportion. 
Renvers  is  of  the  opinion  that  80  to  90  per  cent,  of  all  cases  of  peritonitis  pro- 
ceed from  appendicitis  and  Sonnenburg  believes  that  this  estimate  is  not  too 
high.     Our  statistics  confirm  this  view. 

Diffuse  or  generalized  peritonitis  in  connection  with  appendicitis  may  occur 
in  the  following  ways: 

1.  As  a  result  of  perforation  or  gangrene  of  the  appendix. 

2.  Through  rupture  of  a  circumscribed   peri-appendical   abscess. 

3.  By  means  of  infection  by  continuity  from  the  inflamed  but  not  perforated 
appendix,  or  from  a  circumscribed  intra-  or  extra-peritoneal  abscess  without 
rupture.  In  infection  by  continuity,  the  pathogenic  organisms  penetrate  the 
diseased  but  intact  wall  of  the  appendix,  or  the  limiting  membrane  of  the 
abscess. 

The  frequency  with  which  generalized  peritonitis  follows  a  primarily  Ideal- 
ized peri-appendical  suppuration  is  seen  in  the  autopsy  findings.  In  29  out 
of  54  cases  of  general  peritonitis  there  was  evidence  that  there  had  been  at  first 
a  localizing  process  which  had  resulted  in  a  more  or  less  completely  walled-off 
abscess,  and  that  subsequently  leakage  had  taken  place  from  this  with  a  result- 
ing generalized  peritonitis.  The  remaining  25  cases  revealed  no  sign  of  any 
attempt  to  limit  the  process. 

Perforative  appendicitis  may  he  the  means  of  precipitating  into  the  abdom- 
inal cavity  bacteria  so  virulent  and  in  such  a  quantity  that  death  occurs  within 
a  few  hours,  but  at  the  autopsy  examination  no  perceptible  reaction  on  the 
part  of  the  peritoneum  is  found.  In  these  cases  the  rapidly  fatal  issue  is  due 
to  acute  sepsis,  which  may  be  the  result  of  toxemia  alone  or  of  bacteriemia. 
These  rapidly  fatal  infections  most  often  follow  the  bursting  of  an  acute  peri- 
appendical  abscess,  or  of  an  appendix  distended  with  pus,  the  conditions  in  the 
pent-up  exudate  being  most  favorable  to  bacterial  activities.  This  highly 
septic  material  is  soon  distributed  over  a  large  portion  of  the  peritoneal  sur- 
face and  is  immediately  absorbed.  Murphy  mentions  a  case  in  which  an  abscess 
of  considerable  size  ruptured  into  the  peritoneal  cavity.  In  two  hours  there 
were  symptoms  of  extreme  shock  and  in  twelve  hours  the  patient  was  dead. 
In  these  cases  the  peritoneum  has  not  had  time  to  react  before  the  whole 
organism  is  overwhlemed  by  a  general  toxemia.  Fortunately,  such  cases  are  not 
common,  and  as  a  rule  in  fatal  cases  the  patient  lives  thirty-six  hours  to  three  or 
four  days.     There  is  then  a  well-marked  peritoneal  reaction. 

The  most  fatal  variety  of  peritonitis,  characterized  by  a  very  small  amount 


324  I'ATIIOI.OCY. 

of  exudate,  is  d  r  y  peritonitis  or  peritonitis  septica.  There 
is  usually  only  a  drain  or  two  of  bloody  serum,  and  a  few  scattered  flaki  of 
lymph,  but  the  serosa,  wherever  ii  has  cope  in  contaci  with  the  septic  material, 
[a  an  intense  red  and  has  the  appearance  of  abrasion  due  to  destruction  of  endo- 
thelium. These  cases,  according  to  Mi  rphy,  always  die,  whether  operated  on 
or  not. 

In  most  instances  of  spreading  or  generalized  peritonitis,  result  inn  from 
either  a  perforative  or  a  non-perforative  appendicitis,  there  is  an  abundant 
fibrinc-purulent  exudate,  the  fibrinous  element  in  some  ease-;  being  greatly  in 
excess,  while  at  (it her  times  there  is  a  large  amount  of  purulent  fluid  and  a  very 
slighl  fibrinous  deposil ;  and,  again,  the  solid  and  fluid  exudate  may  be  in  more 
or  less  equal  proportions.  A  copious  serous  or  purulent  exudate  has  been 
shown  to  be  of  great  value  in  diluting  and  thus  delaying  the  absorption  of  the 
septic  material,  while  on  account  of  its  powerful  bactericidal  properties  it  dimin- 
ishes or  entirely  destroys  the  infective  agents.  It  has  frequently  been  noticed 
that  pus,  containing  organisms  of  low  virulence,  may  exist  for  some  time  in  the 
peritoneal  cavity  without  materially  injuring  the  normal  gloss  of  the  serosa. 
Murphy  has  pointed  out  thai  in  cases  of  generalized  purulent  peritonitis  result- 
ing from  appendicitis,  in  which  the  normal  glistening  appearance  of  the  peri- 
toneum was  present  at  the  time  of  operation,  the  patients  recovered,  lie  con- 
trasts these  cases  with  the  invariably  fatal  ones  of  dry  peritonitis  in  which  a 
large  portion  of  the  peritoneum  is  denuded  of  its  endothelial  surface.  The  vast 
majority  of  all  cases  of  diffuse  peritonitis  originating  in  the  appendix  may  be 
regarded  as  belonging  between  these  two  extremes.  In  most  instances  the 
septic  material  is  poured  into  the  peritoneal  cavity  in  relatively  small  quantities, 
and  the  tissues  are  able  to  offer  more  or  less  efficient  resistance  to  its  deleterious 

action.  The  exudate,  at  first  sero-fibrinous,  soon  becomes  purulent  and  an  in- 
creasing amount  of  fibrin  is  present;  the  serous  surfaces  become  injected  and 
lose  something  of  their  normal  lustre.  The  intestinal  loops  may  lie  partly  filled 
together  by  filmy,  fibrinous  adhesions,  or  may  he  almost  wholly  covered  with 
large  plaques  of  fibrin.  Fig.  338  shows  beginning  diffuse  peritonitis  due  to 
infection  by  continuity  from  the  appendical  abscess;  the  loops  of  intestine 
in  the  vicinity  of  the  abscess  being  covered  with  large  plaques  of  yellowish  fibrin. 
Sometimes  the  entire  serosa  is  covered  with  a  continuous  coat  of  fibrin.  Some 
degeneration  ami  exfoliation  of  the  endothelium  is  gradually  produced  by  the 
action  of  the  septic  material.  The  continued  action  of  septic  material  of  low 
or  moderate  virulence  may  ultimately  produce  degeneration  and  inflammatory 
reaction  in  the  external  layers  of  the  intestinal  walls,  the  injury  to  the  muscle 
and  nerve  elements  resulting  in  partial  or  complete  intestinal  paralysis  and 
in  consequence  a  stasis  of  its  contents.  This  is  soon  followed  by  intestinal  fer- 
mentation and  an  increase  in  the  virulence  of  the  contained  micro-organism. 
As  LENNANDER  points  out,  there  is  then  a  twofold  danger  added  to  the  primary 
infection;    first,  in  the  abdominal  distention  pressing  the  diaphragm  upward 


SPREADING    AND    GENERALIZED    PERITONITIS. 


325 


am.1  impeding  both  respiration  and  circulation;  second,  and  more  to  be  dreaded, 

in  .ue  rapidly  increasing  toxicity  of  the  intestinal  bacteria  and  the  altered  con- 
dition of  the  walls  which  permits  the  penetration  of  micro-organisms.  As  a 
result  of  an  intestinal  paralysis  there  is  therefore  increased  general  intoxication 
through  absorption  of  toxic  intestinal  contents  and  increased  general  infection 
through  the  passage  of  the  intestinal  bacteria  into  the  lymph  circulation  and 
blood-vessels. 

In  diffuse  infections,  when  the  reactive  energy  of  the  peritoneum  is  pre- 
served,  a  severe  infection    usually   induces   a   fibrino-purulent   exudate.     The 


Fig.   202. — Chronic  Appendicitis. 
The  appendix  twisted  one-half  around  it^  axis  and  held  in  tin-  position  by  adhesions  extending  from  the  mes 

appendix  to  the  cecum. 


following  case,  in  which  a  fatal  streptoc  o  ecus   infection  was  marked  by 
an  abundant  sero-fibrinous  exudate,  appears  to  be  unusual. 


(J.  H.  H.  Surg.  No.  14,473.)     H.  15..  age  twelve  years.     Admitted  with  a  history 

of  four  days'  illness,  beginning  with  pain  in  the  right  iliac  fossa  and  vomiting. 
Bowels  did  not  move  for  two  days.     The  pain  continued  for  three  days,  then  became 

less  intense.       (  111  admission  the  rectal  telli]  «■  rat  lire  Was  101.8°  F.  |  leucocyte.-.  22,000. 

On  abdominal  examination  there  was  almost  no  tenderness  on  the  left  side,  hut  slight 
tenderness  over  the  whole  right  side,  very  marked  in  the  iliac  region,  where  a  mass 
could  be  fairly  well  outlined.  There  was  no  muscle  spasm.  L'pon  opening  the  abdom- 
inal cavity  the  cecum  presented,  its  surface  covered  with  a  thick  coating  of  white, 
pearly,  translucent  fibrin,  which  could  be  stripped  off  in  distincl  layers.  This  same 
form  of  peritonitis  extended  over  the  vermiform  appendix  and  surrounding  tissues. 


326 


l'\  i  HOLOGT. 


Search  for  the  abscess  was  continued  down  into  the  pelvis,  and  the  appendix  found 
inclining  in  this  direction,  very  much  thickened  and  covered  with  edematous  fibrin 
as  above.  The  tip  of  the  appendix  was  greenish;  the  lumen  was  not  opened.  The 
mass  which  had  been  fell  on  examination  rJroved  qoI  to  be  an  abscess,  l>ut  the  plastic 


Fig.  -Ox. — Pocketed   Appendix   Uksiliim.  prom  Old   Loi  ilized   Peritonitis. 


peritonitis  about  the  cecal  region.  The  appendix  was  removed  and  drainage  inserted. 
Death  occurred  the  nexl  day,  the  whole  picture  being  one  of  rapid  intoxication. 
At  autopsy,  the  s  t  re  p  t  o  C  0  C  c  U  S  was  obtained  from  the  peritoneal  and  pleural 
cavities. 


SPREADING    AXD    GENERALIZED    PERITONITIS.  327 

Generalized  peritonitis  following  appendicitis  is  fatal  in  a  large  proportion 
of  cases,  whether  the  patient  is  subjected  to  operation  or  not.  That  a  spon- 
taneous recovery  may  occur,  however,  is  evident  from  the  operative  and  autopsy 
findings  in  a  number  of  cases.  Generalized  adhesions  uniting  the  various  parts 
of  the  intestine  to  one  another  and  to  the  abdomen  are  unquestionable  proof 
of  the  former  existence  of  a  peritonitis.  When  these  adhesions  are  especially 
dense  in  the  appendix  region,  and  the  appendix,  which  is  embedded  in  adhesions. 
is  partially  or  totally  obliterated,  or  else  presents  other  evidence  of  an  old 
inflammation,  the  origin  of  the  peritonitis  is  evident. 

The  following  case,  in  which  the  patient  had  evidently  recovered  from  a 
diffuse  peritonitis  due  to  appendicitis,  is  of  interest  in  this  connection  and  also 
indicates  that  obliteration  of  the  appendix  is  often  of  inflammatory  origin: 

(J.  H.  H.  Surgical  No.  15.615.)  F.,  age  twenty-five.  The  patient  had  had  a 
severe  attack  of  peritonitis  when  nine  years  of  age.  She  grew  up  a  strong  airl. 
but  was  never  able  to  ride  on  horseback  on  account  of  the  pain  which  it  caused  in 
the  right  lower  abdomen.  Four  years  previously  she  was  ill  for  three  weeks  with 
a  typical  attack  of  appendicitis,  and  afterwards  suffered  from  a  constant  dull  pain 
in  the  right  iliac  region.  Operation  revealed  several  flimsy,  fibrous  adhesions, 
evidently  the  remains  of  an  old.  very  extensive  peritonitis.  The  appendix,  which 
was  strongly  adherent,  was  almost  obliterated,  only  the  proximal  1  cm.  possessing  a 
lumen.  The  median  portion  was  converted  into  a  thin  fibrous  band,  while  the  bulb- 
ous tip  contained  a  stercoral  concretion.  Operation  resulted  in  the  complete  cessation 
of  the  abdominal  tenderness  and  pain. 

In  a  case  reported  by  Markoe,  a  child  who  presented  symptoms  of  general 
peritonitis  on  the  second  day  of  an  attack  of  appendicitis,  died  within  a  year 
from  another  disease.  Autopsy  showed  a  perforated  appendix  and  the  intes- 
tines adherent  in  different  places  (see  Chap.  XXII). 

The  adhesions  resulting  from  a  localized  or  diffuse  peritonitis  may  be  velamen- 
tous  in  character,  uniting  the  neighboring  structures  by  delicate,  transparent 
fibres,  or  they  may  be  more  dense,  and  by  producing  twists  and  angulations 
of  the  appendix  form  one  of  the  chief  causes  of  subsequent  attacks  isee  Figs. 
148  and  202).  The  appendix  may  be  completely  hidden  by  adhesions,  as  in 
Fig.  203.  Sometimes  adventitious  pockets  may  be  formed  in  the  cecal  region, 
in  which  the  appendix  may  become  incarcerated.  In  other  instances  the 
adhesions  consist  of  fine  thread-like  strands  or  dense  fibrous  cords,  which  ex- 
tend in  various  directions  from  the  appendical  region,  and  are  a  common  source 
of  intestinal  obstruction. 


.      CHAPTER  XIV. 
PATHOLOGY. 
BLOOD-VASCULAR  INFECTION.     LYMPHATIC  INFECTION. 
BLOOD-VASCULAR    INFECTION. 

Of  the  remoter  complications  of  appendicitis,  those  depending  upon  the 

extension  of  the  disease  by  way  of,  and  involving  the  blood-vessels  are  particu- 
larly interesting.  As  explained  in  the  section  on  anatomy,  the  main  blood- 
stream is  tributary  to  the  portal  system,  but  in  some  instances,  by  means  of 
small  branches  anastomosing  a  communication  is  established  through  collat- 
eral branches  with  the  ileo-lumbar  veins,  and,  in  obstruction  of  the  portal  route, 
with  the  systemic  veins.  Moreover,  in  pathological  conditions  other  routes  may 
be  formed,  through  the  medium  of  adhesions,  by  which  the  blood  from  the 
appendical  vessels  may  even  pa<s  directly  into  the  general  circulation. 

A  cute  phlebitis,  p  y  o-phlebitis,  or  t  h  r  o  m  1>  os  is  occurs 
as  a  complication  or  sequel  of  appendicitis,  and  may  give  rise  to  infarction,  or 
tn  suppuration  of  the  region  supplied  by  the  affected  vessel,  or  through  the 
various  anastomoses  with  the  general  circulation,  they  may  result  in  embolism, 
or  in  a  genera]  pyemic  process. 

While  slowing  and  other  irregularities  of  the  blood  flow  and  alterations  in 
the  vessel  walls  are  important  accessory  factors  in  the  causation  of  thrombosis, 
the  chief  factor  in  its  production  is  unquestionably  an  inflammatory  process 
clue  to  the  agency  of  micro-organisms.  The  infective  agent  excites  an  endo- 
phlebitis  or  endarteritis  which  in  turn  gives  rise  to  the  thrombosis.  The  in- 
fection of  the  Lntima  may  occur  in  one  of  two  ways :  the  vessel  may  be  involved 
in  an  inflammatory  process  and  the  organisms  which  are  the  cause  of  the  inflam- 
mation invade  the  external  coats,  and  from  there,  by  way  of  the  vasa  vasorum 
or  the  lymphatics,  gain  access  to  the  uitima:  or  (more  frequently)  the  bacteria 
enter  directly  from  the  circulating  blood.  Welch  believes  also  thai  a  form  of 
toxic  endangeitis  which  he  describes,  i<  of  importance  in  the  causation  of  throm- 
bosis complicating  infective  and  cachectic  states.  The  lesion  which  is  seen  in 
the  intima  of  veins,  less  frequently  of  arteries,  consists  of  a  nodular,  sometimes 
more  diffuse,  accumulation  of  lymphoid  or  endothelioid  cell-  beneath  the  endo- 
thelium of  the  vessel  wall.  These  cells,  as  well  as  the  covering  endothelium, 
may  undergo  necrosis;  the  appearance,  indeed,  sometimes  suggesting  a  primary 
necro-q<  with  secondary  accumulation  of  wandering  cells  and  proliferation  of 
fixed  cells.  It  has  been  shown  that  these  foci  may  unquestionably  be  the  start- 
328 


BLOOD-VASCULAR   IXFECTIOXS.  329 

ing-point  of  a  thrombosis.     Although  this  form  of  endophlebitis  and  endarteritis 
resembles  that  demonstrably  caused  by  the  actual  presence  of  bacteria  in  the 

intima.  bacteria  are  often  absent  even  in  fresh  lesions,  so  that  it  is  reasonable 
to  suppose  that  the  affection  may  be  caused  by  toxins.  The  small  vessels  and 
capillaries  in  the  vicinity  of  erosions  and  suppurative  foci  regularly  show  septic 
inflammation  and  frequently  contain  thrombi  composed  almost  wholly  of  a 
plug  of  leucocytes,  fibrin,  or  hyaline  material.  In  the  larger  vessels  there  are 
thrombi  of  the  white  or  red  variety,  or  there  may  be  a  combination  of  the  two 
forms.  The  thrombus  rarely  involves  the  entire  circumference  of  the  vessel, 
but  more  commonly  is  laterally  adherent,  so  that  the  blood  is  not  impeded. 
Later,  however,  complete  obstruction  of  the  vessel  lumen  may  occur.  As  a 
rule,  the  thrombosis  increases  in  the  direction  of  the  circulation,  but  a  certain 
amount  of  growth  also  frequently  occurs  in  the  opposite  direction  (Fig.  153 
A  continued  or  propagated  thrombosis  extends  along  the  course  of  the  vessel 
and  sometimes  into  communicating  vessels;  or  a  portion  of  the  thrombus  may 
be  carried  to  a  distant  point  and  form  the  starting-point  of  a  secondary 
thrombus. 

The  fairly  recent,  white  thrombus  appears  as  a  compact,  firm,  elastic,  fibrous 
mass,  which  is  not  easily  broken  up.  It  may  show  a  definite  trabecular 
structure,  but  often  becomes  granular  or  almost  homogeneous.  Histo- 
logically, the  thrombus  consists  of  lamellae  of  platelets,  fibrin,  and  leu- 
cocyte-, and  upon  the  surface  a  denser  band  of  fibrin  and  leucocytes.  The  red 
thrombus  is  simply  a  blood  clot  covered  with  a  secondary  deposit  of  the  ele- 
ments which  enter  into  the  formation  of  the  white  thrombus.  A  mixed  throm- 
bus may  be  due  to  an  intimate  mixture  of  gray  and  red  substance,  to  stratified 
gray  and  red  layers,  or  to  red  propagated  clots  consecutive  to  primary  white 
or  mixed  thrombi.  In  older  thrombi  the  platelets  and  leucocyte-  degenerate 
and  there  is  an  increase  and  condensation  of  the  fibrinous  constituents.  In  red 
and  mixed  thrombi  the  red  blood  corpuscles  become  disintegrated,  and  there 
is  later  a  deposit  of  brownish  pigment. 

If  the  infective  process  is  arrested  the  thrombus  undergoes  speedy  organiza- 
tion, being  replaced  by  the  products  of  a  proliferative  endangeitis.  Often. 
however,  especially  if  the  larger  veins  be  the  seat  of  the  trouble,  the  auto- 
infection  goes  on  until  the  whole  vein,  or  series  of  veins  is  filled  with  puriform 
fluid:  or.  septic  embolism  may  form  with  the  production  of  secondary  thrombi 
with  local  abscesses,  or  with  a  general  pyemia. 

Thrombosis  of  the  appendical  vessels,  as  before  explained,  is  not  infrequent 
in  both  the  arterial  and  venous  branches  traversing  the  walls  of  the  appendix 
itself,  but  is  less  common  in  the  main  appendical  vessels  in  the  mesenteriolum. 
It  is  true  that  when  total  gangrene  or  spontaneous  separation  of  the  appendix 
from  the  cecum  has  occurred,  the  chief  cause  of  the  necrosis  is  an  obstruction  to 
the  circulation,  either  from  external  pressure  or  from  thrombosis;  but  this  com- 
paratively frequent  accident  is  seldom  associated  with  or  followed  by  a  con- 


330  PATHOLOGY. 

tinued  infective  thrombo-angeitis.  The  thrombosis  which  servos  to  close  the 
open  proximal  ends  of  the  divided  vessels  may  be  merely  part  of  the  general 
necrotic  process,  or  it  may  be  simple  clotting  such  as  occurs  in  non-infective  as 

well  as  in  infective  conditions,  and  is  rapidly  replaced  by  organized  tissue. 
Gersteb  describes  three  unusually  instructive  cases  of  thrombosis  of  the  main 
appendical  vessels,  which  he  has  personally  observed.  In  one  case  total  gan- 
greneof  the  appendixwas  associated  with  septic  thrombosis  oi  the  vessels  in  the 
mesappendix,  and  later  gave  rise  to  secondary  purulent  thrombo-phlebitis  of 
the  portal  vein  with  subsequent  multiple  liver  abscesses.  Operation  was  per- 
formed twenty-four  hours  after  the  first  onset  of  the  illness,  and  twelve  horns 
after  the  first  rigor.  The  appendix  was  found  dusky,  almost  slate  colored,  and 
tensely  distended.  It  was  free  from  adhesions.  The  niesentoriolum  was  noticed 
to  be  excessively  brittle,  permitting  the  ligature  to  cut  through  it  immediately, 
and  as  blood  (lowed  neither  from  vein  nor  artery  it  was  concluded  that  these 
vessels  must  be  occluded.  In  the  course  of  the  next  twenty-four  hours  there 
was  considerable  improvement  in  the  patient's  general  condition,  and  the  peri- 
toneal symptoms  vanished.  This  temporary  improvement,  however,  was  soon 
succeeded  by  the  characteristic  symptoms  of  septic  pylephlebitis,  and  death 
ensued  on  the  seventeenth  day.  Autopsy  showed  purulent  phlebitis  of  the 
portal  vein  and  multiple  abscesses  of  the  liver. 

In  the  two  other  cases,  one  perforative  purulent  appendicitis,  the  oilier  acute 
gangrenous  appendicitis,  the  veins  in  the  mesappendix  and  the  adjoining  caput 
coli  were  found  to  contain  purulent  thrombi.  In  each  case,  after  removal  of 
the  appendix,  the  thrombosed  vessels  were  incised  and  drained  and  the  patients 

recovered. 

Involvement  of  the  mesenteric  vessels  in  the  thrombotic  process  usually 
results  in  a  more  or  less  extensive  hemorrhagic  infarction  of  the  intestine;  in 
some  instances  only  a  small  portion,  less  than  the  area  supplied  by  the  throm- 
bosed vessel,  is  infarcted;  in  other  cases  a  much  larger  area  is  affected.  The 
more  acute  the  thrombotic  process,  the  more  liable  is  infarction  to  occur.  A 
slowly  obturating  thrombus,  or  one  secondary  to  portal  thrombosis,  in  which  a 
collateral  circulation  has  been  established,  may  not  result  in  infarction;  but, 
on  the  other  hand,  acute  portal  thrombosis  may  cause  extensive  intestinal  in- 
farction in  the  absence  of  any  disease  of  the  intestinal  vessels.  Embolism,  and 
more  rarely  autochthonous  thrombosis  of  the  mesenteric  arteries,  is  more  com- 
monly the  cause  of  intestinal  infarction  than  disease  of  the  veins.  The  obstruc- 
tion may  be  situated  in  the  superior  mesenteric  artery  or  in  any  of  its  brandies. 
As  in  the  case  of  venous  thrombosis,  gradual  closure  of  the  artery  may  not  be  fol- 
lowed by  infarction.  The  common  source  of  an  embolus  is  the  left  heart,  or 
the  aorta,  but  primary  thrombosis  of  the  arteries  may  accompany  infective 
diseases.  As  a  complication  or  sequel  of  appendicitis,  disease  of  the  mesenteric 
veins  is  apparently  more  frequent  than  disease  of  the  arteries  and  is  often 
associated   with   portal   infection.     Hemorrhagic  infarction  of  the  intestines  in 


BLOOD- VASCULAR   INFECTIONS.  331 

these  cases  is,  however,  exceedingly  rare.  In  the  fairly  extensive  literature 
relating  to  thronibo-phlebitis  and  in  the  vast  literature  concerning  appendicitis 
this  condition  is  apparently  not  mentioned.  Of  the  ten  cases  of  purulent  phle- 
bitis and  thronibo-phlebitis  of  the  portal  vein  described  in  Chap.  X,  the  majority 
showed  involvement  of  the  superior  mesenteric  vein  or  some  of  its  branches,  but 
none  showed  any  evidence  of  infarction,  with  one  exception,  Case  VII,  p.  235, 
where  the  infarction  was  very  incomplete.  In  this  case  the  branches  of  the 
superior  mesenteric  vein  running  from  the  lower  part  of  the  ascending  colon  were 
occluded  by  rather  friable,  slightly  adherent  thrombi,  and  the  main  stem  of 
the  vein  contained  a  firmly  adherent  thrombus.  The  small  intestine  showed 
many  large  areas  of  congestion  and  submucous  hemorrhages,  and  the  colon  was 
hyperemic.  In  this  connection,  the  following  case  of  Gibbon's  furnished  me 
by  Longcope  is  of  unusual  interest: 

The  patient,  a  colored  man  nineteen  years  old,  died  two  and  one-half  days  after 
operation  for  acute  perforative  appendicitis  associated  with  purulent  peritonitis. 
At  the  time  of  operation  it  was  noted  that  the  cecum  presented  a  gangrenous  area 
about  the  size  of  a  twenty-five-cent  piece,  which  did  not  appear  to  lie  in  contact 
with  the  appendix.  Autopsy  showed  a  fresh  fibrinous  exudate  covering  the  congested 
omentum  and  intestinal  coils,  while  in  the  region  of  operation  the  omentum  and  intes- 
tines were  matted  together  with  a  thick  whitish-yellow,  soft,  friable  exudate.  The 
intestines  were  distended,  with  the  exception  of  the  cecum  and  the  terminal  portion 
(twelve  inches)  of  the  ileum,  which  were  purplish  in  color,  flaccid,  and  collapsed. 
The  vessels  of  the  mesentery  leading  to  this  portion  were  widely  distended.  The 
ileocolic  veins  contained  a  red  and  white  thrombus  which  extended  for  about  5  cm. 
into  the  two  branches  supplying  the  cecum  and  lower  portion  of  the  ileum.  In  these 
branches  the  thrombus  contained  purulent  material.  About  the  thrombosed  vessels 
the  mesenteric  glands  were  enlarged  and  softened,  one  being  5  cm.  in  size.  Cutting 
open  the  infarcted  area  of  intestine  it  was  found  to  contain  a  thick,  soft,  brick-red 
material.  The  wall  of  the  ileum  was  deeply  congested,  the  mucosa  was  almost  black 
and  showed  small  areas  of  superficial  ulceration.  The  cecum  presented  a  similar 
appearance.  The  surface  of  the  liver  presented  three  or  four  dark  red.  slightly  ele- 
vated, well  outlined,  infarcted  areas,  1.5  to  4  cm.  in  diameter.  The  remaining 
surface  was  finely  granular,  and  mottled  red  and  yellow.  The  consistency  of  the 
liver  was  softened. 

In  a  remarkable  case  of  Finney's  a  primary  thrombo-angeitis  was  believed 
to  have  been  the  cause  of  the  appendical  disease.  At  the  first  operation  the 
appendix  was  greatly  swollen,  almost  black  in  color,  and  it  was  noted  that  the 
main  vessels  were  completely  occluded.  At  a  second  operation  some  days  later 
there  was  found  an  extensive  thrombo-phlebitis  involving  practically  all  of  the 
mesenteric  vessels. 

The  probable  explanation  of  the  exceptional  occurrence  of  intestinal  infarct i<  in 
in  appendicitis  is  that  there  is  not  usually  a  completely  obturating  thrombus, 
a  pyo-phlebitis  being  more  commonly  found.        But,  on  the  other  hand,  this 


332  PATHOLOGY. 

Complication  of  appendicitis  may  not  be  so  rare  as  il  seems  to  be  from  the 
few  cases  recorded  as  such.  In  fatal  cases  it  is  sometimes  mentioned  that  large 
areas  of  the  cecum  or  other  portions  of  the  intestine  are  gangrenous,  a  condition 
which  is  probably  the  result  of  infarction.  In  the  Enq/clopidie  M&hodique, 
1790,  tom.  II,  a  case  is  described  in  which,  associated  with  an  inflamed  appen- 
dix containing  a  foreign  body,  the  liver  was  found  enormously  enlarged  and 
softened  while  the  jejunum  and  pari  of  the  ileum  were  gangrenous  in  places  and 
generally  inflamed.  The  wall  of  the  completely  infarcted  area  of  intestine  is 
thickened,  edematous,  of  a  dark  red  color  from  infiltration  with  blood,  and 
covered  with  lustreless  peritoneum.  The  margins  of  the  infarct  are  often  sharply 
marked,  but  may  pass  gradually  into  the  normal  tissue.  The  mucous  mem- 
brane is  necrotic,  often  defective,  and  may  be  covered  with  a  diphtheritic  exu- 
date. A  considerable  area  of  the  intestine  may  be  gangrenous;  the  lumen 
contains  black,  tarry  blood.  There  is  bloody  fluid  in  the  peritoneal  cavity  and 
usually  a  fibrinous  or  fibro-purulent  exudate  covering  the  infarction:  there  may 
be  genera]  peritonitis.  The  mesentery  is  edematous  and  hemorrhagic.  In  less 
complete  infarction  the  extravasation  of  blood  may  be  limited  to  the  mucosa 

or  submucosa  l  Welch). 

The  most  frequent  complication  of  infective  angeitis  and  thrombosis  follow- 
ing appendicitis  is  the  extension  of  mesenteric  and  portal  infections  to  the 
liver,  by  means  of  a  propagated  thrombus,  or  by  embolic  transplantation,  with 
consequent  acute  hepatitis,  infarctions,  or  liver  abscesses.  This  condition,  as 
also  the  lesions  found  in  the  spleen  and  kidney,  have  been  fully  described  in 
Chap.  X. 

Thrombosis  of  the  peripheral  veins,  ami,  less  frequently,  the  arteries,  nun- 
occur  as  a  complication  of  an  attack  of  appendicitis,  but  much  i "e  frequently 

develops  as  a  post-operative  sequel.  All  the  cases  observed  al  the  Johns  Hop- 
kins Hospital  belong  to  the  latter  group  and  will  be  considered  in  connection 
willi  other  post-operative  complications.  Thrombosis  of  the  iliac  and  femoral 
vessels  may  be  due  to  direct  extension  of  the  infection  from  a  surrounding  in- 
flammatory mass,  or  to  infection  from  the  circulating  blood,  and  may  develop 
on  the  left  as  well  as  on  the  right  side,  the  reported  cases  being  about  equally 

distributed  between  the  two  sides.  Sometimes  both  sides  are  involved,  either 
simultaneously  or  at  different  times.  In  the  majority,  this  complication  oc- 
curred during  the  course  of  a  chronic  appendicitis  or  after  the  subsidence  of  an 
acute  attack. 

PETET  cites  a  case  in  which  a  mild  chronic  appendicitis  was  accompanied 
by  thrombosis  of  the  left  femoral  vein,  and  also  reports  another  ease  in  which 
the  subsidence  of  an  acute  attack  was  followed  by  thrombosis  of  the  right  femoral 
vein  with  subsequent  lung  embolism.  There  are  several  cases  recorded  in  which 
thrombo-angeitis,  consecutive  to  appendicitis,  resulted  in  the  permanent  closure 
of  the  affected  vessel.  In  some  instances,  an  efficient  collateral  circulation 
was  established,  in  others  the  edema  and  the  discomfort  persisted  indefinitely, 


LYMPHATIC    INFECTIONS.  333 

and  in  others  still,  the  artery  being  involved,  there  was  gangrene  of  the  part 
supplied  by  the  occluded  vessel.  Scheibenzuber  has  described  a  rase  of  peri- 
typhlitis complicated  by  embolism  of  the  left  anterior  tibial  artery  with  gan- 
grene of  the  leg  (see  Chap.  IX,  p.  209). 

Berard  relates  a  case  in  which  at  autopsy  on  an  individual  who  had  died 
in  the  third  week  of  the  attack,  a  perforated  gangrenous  appendix  was  found 
associated  with  complete  occlusion  of  the  left  crural  artery.  The  obliteration 
was  due  to  the  presence  of  a  firm  clot  which  presented  traces  of  beginning 
disorganization. 

A  common  sequence  of  throinbo-phlebitis,  and  probably  the  frequent  cause 
of  sudden  death  occurring  during  an  attack  of  appendicitis,  as  the  attack  is 
subsiding,  or  following  operation,  is  the  occurrence  of  lung  embolism.  Petet 
has  collected  three  instances  from  the  literature,  and  has  added  five  unpublished 
cases.  Of  these  cases,  two  presented  the  physical  signs  of  a  small  area  of  in- 
farction in  the  lungs,  but  recovered.  In  six  cases  sudden  death  occurred,  and 
the  diagnosis  was  confirmed  at  autopsy. 


LYMPHATIC  INFECTION. 

In  inflammatory  diseases  of  the  appendix  the  infection  may  spread  by  way 
of  the  lymphatics  and  may  give  rise  to  a  general  septicemia,  to  localized 
lymph-adenitis,  or  by  direct  continuity  may  produce  suppuration  in  the  hepatic 
or  subphrenic  regions. 

The  extension  of  the  infective  process  by  way  of  the  neighboring  lymphatics 
into  the  thoracic  duct,  and  so  into  the  general  circulation,  is  the  usual  origin 
of  a  general  septicemia  accompanying  both  suppurative  and  non-suppurative 
forms  of  appendicitis,  and  occurs  either  in  the  presence  or  absence  of  peritoneal 
involvement.  The  localized  lymphatic  infections  have  received  comparatively 
little  attention,  but  are  of  considerable  importance,  in  that  a  focus  of  infection 
in  the  lymph  glands  may  be  the  cause  of  a  prolonged  illness  following  the  re- 
moval of  the  appendix.  The  glands  may  suppurate,  with  subsequent  abscess 
formation  in  the  retrocecal  or  retrocolic  region,  ami  as  explained  before 
(Chap.  X)  may  be  the  source  of  subphrenic  and  hepatic  infection.  A  mild 
chronic  appendicitis  as  well  as  an  acute  suppurative  affection  may  give  rise 
to  a  severe  lymph-adenitis.  Moreover,  the  lymphatic  infection  may  remain 
latent  for  months  and  then  develop  an  acute  process.  Ricard  removed 
the  appendix  during  an  acute  attack  of  inflammation,  marked  by  an  appearance 
of  sub-icterus,  and  the  patient  was  discharged,  apparently  cured.  Some  time 
afterward  he  returned  with  the  same  symptoms,  and  his  condition  becoming 
grave,  Ricard  again  opened  the  abdomen  and  found  a  chain  of  infected  lymph 
glands  extending  from  the  site  of  the  appendix  toward  the  liver,  the  first  two 
being  enlarged  and  suppurating.  Four  or  five  glands  were  extirpated,  and 
the  patient  made  an  uninterrupted  recovery. 


334  PATHOLOGY. 

Rendu  describes  a  case  of  appendicitis  of  obscure  development,  presenting 
symptoms  of  pyemia  on  the  thirteenth  day  and  resulting  in  death  ten  days 

later.  The  appendix  was  tumid  lying  in  an  abscess  the  size  of  an  egg  in  the 
psoas  muscle.  The  mesenteric  glands  corresponding  to  the  ileocecal  region 
were  enormous,  some  being  as  large  as  an  egg.  They  were  red.  hard,  and  in- 
jected; two  had  broken  down,  their  centres  containing  putrid  pus.     There  were 

several  abscesses  in  the  liver.  Unfortunately  the  mesenteric  vessels  were  not 
examined;    the  portal  vein,   however,  was  healthy. 

In  a  case  reported  byAtTGUY,  after  two  attacks  of  appendicitis  an  opera- 
tion h  jrniil  was  performed.  The  appendix  was  found  slightly  adherent  ill  the 
retrocecal  position.  In  the  vicinity  of  the  ileocecal  angle  was  a  group  of  seven 
or  eight  firm,  movable,  non-adherent  glands.  One  of  these,  removed  for  bac- 
teriological examination,  furnished  a  characteristic  culture  of  bacillus 
coli.     The  patient  made  an  uneventful  recovery. 

In  several  other  cases  described  by  AuGTJY  and  FERRY,  infected  lymph 
glands  were  found  in  the  mesenteriohmi.  In  one  case  in  which  the  appendix 
was  only  slightly  enlarged  and  a  little  reddened,  the  niesappendix  contained 
a  suppurating  gland  the  size  of  a  small  nut. 

Slight  enlargement  of  the  glands  is  to  be  expected  in  all  active  inflamma- 
tions, and  on  removal  of  the  primary  focus  of  infection  will  soon  subside.  Sup- 
purating glands,  on  the  other  hand,  will  often  give  rise  to  further  mischief, 
and  in  all  cases  they  should  be  removed  or  thoroughlv  drained. 


CHAPTER  XV. 
PATHOLOGY. 

tuberculosis.    actinomycosis.   typhoid  fever.   amcebic  dysentery. 

Specific  Inflammatory  Diseases  of  the  Appendix. 

By  specific  inflammatory  affections  is  understood  that  group  of  cases  in 
which  a  more  or  less  distinctive  inflammatory  process  is  produced  in  the  tissue 
by  the  action  of  the  specific  micro-organisms  of  the  disease.  Probably  in  most 
instances  there  is  not  a  pure  infection  with  the  specific  organism,  as  sooner 
or  later  a  secondary  infection  with  the  ordinary  pyogenic  bacteria  is  engrafted 
upon  the  primary  disease,  so  that  in  many  cases  the  characteristic  lesions  are 
not  detected.  The  principal  affections  of  the  appendix  belonging  to  this  divi- 
sion are,  tuberculosis,  actinomycosis,  typhoid  fever, 
and     a  m  ce  b  i  c     d  y  s  e  n  t  e  r  y . 

TUBERCULOSIS. 
Tuberculosis  of  the  appendix  may  be  primary  or  secondary,  the  latter  con- 
dition being  due  to  direct  extension  from  the  cecum,  or  to  transplantation  of 
the  infective  agent  from  some  distant  organ,  usually  the  lungs,  in  which  case 
the  tubercular  lesions  may  be  disseminated  throughout  the  entire  intestinal 
tract,  or  may  be  limited  to  the  appendix.  In  most  instances  the  affection  of 
the  appendix  is  part  of  an  ileocecal  tubercular  process,  the  disease,  as  a  rule, 
probably  originating  in  the  cecum,  and  extending  by  continuity  of  structure 
to  the  appendix.  Occasionally,  however,  the  appendix  presents  the  more 
advanced  lesions,  and,  again,  it  is  impossible  to  determine  which  organ  con- 
tains the  primary  focus  of  infection.  In  rare  instances  the  tubercular  process 
is  apparently  limited  to  the  appendix,  but,  on  the  other  hand,  very  extensive 
disease  of  the  cecum  may  exist  without  any  involvement  of  that  organ.  The 
simple  involvement  of  the  peritoneal  coat  of  the  appendix  in  a  general  miliary 
tuberculosis  need  only  be  mentioned  here,  as  it  presents  no  special  pathological 
features  referable  to  the  appendix,  apart  from  the  fact  that  adhesions  may 
form  which  may  lead  to  an  attack  of  acute  inflammation.  There  are  two  dis- 
tinct types  of  tubercular  disease  of  the  appendix,  when  primary  or  when  secon- 
dary to  the  ileocecal  affection:  the  usual  ulcerative  or  caseous  variety,  and 
the  less  common  form,  which  is  characterized  by  a  massive  connective  tissue 
production,  the  so-called  hyperplastic  tuberculosis.  The  former  is  often  asso- 
ciated with  a  generalized  intestinal  infection,  whereas  the  latter,  as  a  rule,  is 

335 


336  PATHOLOGY. 

localized  in  the  cecal  region.  Cornil  and  Richelot  call  attention  to  a  third 
variety  in  which  a  secondary  colon  bacillus  infection,  superimposed 
upon  the  tubercular  infection,  results  in  a  suppurative  appendicitis,  the  primary 
tuberculosis  disappearing  in  the  midst  of  the  purulent  focus.  This  condition, 
however,  although  of  considerable  interest,  is  of  the  nature  of  a  mixed  or 
terminal  infection,  and  cannot  be  considered  a  distincl   form  of  tuberculosis. 

Caseous  or  ulcerative  tuberculosis  of  the  appendix 
in  man}'  cases  is  not  recognized  upon  macroscopic  examination.  The  ex- 
terior of  the  appendix  may  present  nothing  to  distinguish  the  condition  from 
a  simple  chronic  or  subacute  inflammation.  The  serosa  is  usually  injected. 
In  all  the  cases  which  have  come  under  my  observation  adhesions  have  been 
present,  usually  very  light  and  veil-like.  In  Case  2*  the  worm-eaten  appear- 
ance of  the  serous  surface  was  commented  upon  at  the  time  of  the  operation, 
but  the  true  nature  of  the  disease  was  not  suspected  until  revealed  by  the  micro- 
scope. In  Sonnenbi  bg's  case  a  few  gray  miliary  tubercles  were  scattered 
over  the  serosa  in  the  vicinity  of  the  thickened  proximal  portion  of  the  appendix. 
The  appendix  is  usually  thicker  than  normal.  In  Sonnenburg's  case  the  prox- 
imal end  with  the  anterior  wall  of  the  cecum  formed  a  dense  tumor,  while  the 
distal  portion,  though  thicker,  was  soft.  In  MoSHER's  case  the  appendix  was 
long  and  tensely  distended.  In  Case  'A  the  appendix  was  diminished  in  size, 
resembling  a  withered,  obliterated  organ.  A  careful  examination  of  the  in- 
terior may  he  more  fruitful  of  results.  The  mucous  membrane  is  injected 
and  shows  more  or  less  extensive  ulcerations,  which  have  the  characteristic 
caseous  appearance  of  tubercular  disease.  The  individual  ulcer  may  he  round 
or  oval,  or  it  may  encircle  the  lumen  of  the  appendix.  The  floor  of  the  ulcer 
and  the  surrounding  mucosa  may  he  beset  with  minute  grayish  tubercles.  In 
some  instances  almost  the  entire  mucous  membrane  is  caseous.  In  Case  :; 
the  mucosa  was  replaced  by  partly  caseous,  partly  fibrous  tubercular  products 
which  caused  complete  obliteration  of  the  canal.  BlGGS  presented  a  specimen 
of  tuberculosis  of  the  appendix,  in  which  about  one  inch  of  the  extremity  was 
cut  off  from  the  remainder,  and  was  filled  with  cheesy  material.  Where  the 
intestinal  tuberculosis  is  a  late  complication  of  lung  tuberculosis,  the  process 
rapidly  spreads,  owing  to  the  slight  resistance  of  the  organism,  and  ulcers  are 
produced  which  show  no  tendency  to  heal.  These  ulcers  are  apt  to  be  espe- 
cially deep  in  the  cecum  and  appendix,  and  may  proceed  to  perforation.  On 
the  other  hand,  when  the  disease  is  limited  to  the  cecum  or  the  appendix,  or 
is  merely  associated  with  a  latent  or  healed  focus  in  some  other  part,  a  repara- 
tive process  maybe  established,  with  a  subsequent  cicatrization  of  the  ulcerated 
areas,  and,  ultimately,  the  production  of  strictures.  Annular  ulcers,  especially, 
may  result   in  almost   complete  stenosis. 

Histological  E  x  a  m  i  n  a  t  i  o  a . — Histologically  the  characterist  ic 
lesions  of  tuberculosis  are  found.  As  a  rule,  the  process  is  principally  confined 
to  the  mucous  and  submucous  layers,  in  some  cases  the  former,  in  other  cases 
*  For  clinical  histories  of  these  r;is<-s,  see  Chap.  XXXII. 


TUBERCULOSIS. 


337 


the  latter,  showing  the  most  pronounced  changes.  As  a  rule,  a  few  scattered 
foci  are  found  in  the  peritoneal  layer.  Tn  Fig.  204  the  maximum  lesions  are 
found  in  the  submucosa,  which  is  much  thickened  and  almost  wholly  made  up 


dSSSK  . 


e 

....  dM 


■'  -J?.^ 


mm:  1  " 


Fig.  204. — Tuberculosis  of  the  Appendix.     Maonifieh  40  Times. 
A  indicates  a  remnant  of  the  mucosa  which  has  disappeared  in  other  places;  b  is  the  submucosa;  c,  the 
circular  and  */  the  longitudinal  muscular  coats.     Tubercles  (e)  are  chiefly  found  in  the  submucosa,  but  also  invade 
the  musculature.     At  y  a  caseous  area  is  seen.     (Specimen  from  I.  Henrotin.) 


of  tubercular  tissue.  The  mucosa  is  almost  completely  destroyed.  A  few  small 
tubercular  foci  and  areas  of  caseation  are  seen  in  the  musculature  and  peri- 
toneal layers.     In  Case  2  the  mucous  membrane  was  but  little  altered,  while 


338 


P\    I    llMl.dl.l    . 


the  submucosa  was  studded  with  miliary  and  conglomerate  tubercles,  showing 
extensive  areas  of  caseation.  Usually,  however,  there  is  more  or  less  destruc- 
tion of  the  mucosa,  and,  as  we  have  seen,  it  may  be  entirely  replaced  by  tuber- 
cular products.  Typical  miliary  tubercles  predominate  in  some  cases,  while  in 
others  the  most  conspicuous  feature  is  a  diffuse  fibrino-caseous  process.  In 
Case  ;!  typical  tubercles  were  not  .-ecu  and  the  centre  of  the  appendix  con- 
sisted almost  wholly  of  epithelioid  cells  and  caseous  material.  Tubercle  bacilli 
are  easily  demonstrated  in  mosl  cases,  but  are  rarely  numerous. 

At  a  later  stage,  the  invasion  of  secondary  organisms  may  induce  a  purulent 
process,  which  obscures  the  tubercular  lesions.  In  other  cases  there  is  a  com- 
plete fibrous  transformation  of  the  diseased  area-,  and  it  is  only  on  the  examina- 
tion of  numerous  sections  that  the  tubercular  origin  of  the  process  is  revealed. 
In  these  conditions  the  regional  lymph  glands  frequently  show  an  active  tuber- 
cular process. 

Hyperplastic  Tuberculosis. — Since   1891,   when    Haetmann  and    Pilliet 

published  the  first 
detailed  description 
of  this  form  of  in- 
testinal tuberculosis, 
many  cases  have 
been  reported,  in  the 
vasi  majority  of 
which  the  cecal  re- 
gion  was  the  seal  of 
the  disease.  The  ap- 
pendix,    as    a     rule. 

Was  not  affected,  but 
in  some  instance-  it 
wa-  involved  in  the 
cecal  tumor.  I  have  found  only  one  record  in  which  the  process  was  primary  in 
ami  practically  confined  to  the  appendix.  This  case  was  described  by&tOWDER, 
to  whose  courtesy  I  am  indebted  for  notes  of  the  case  and  for  the  specimen  pic- 
tured in  Figs.  I'D").  206,  and  L'OT.  The  appendix,  which  was  removed  at  opera- 
tion, together  with  a  -mall  portion  of  the  adjacent  cecal  wall,  lias  been  hard- 
ened in  alcohol  and  consequently  has  undergone  some  shrinkage.  It  is  6  cm. 
long,  and  in  diameter  varies  from  18  to  20  nun.  in  the  thick  median  portion,  and 
is  11  mm.  near  the  cecal  end.  It  is  very  firm  and  hard,  and  its  surface  near 
the  middle  is  marked  by  smooth  rounded  elevation-,  consisting  of  infiltrated 
masses  of  subperitoneal  fat.  The  peritoneum,  with  the  exception  of  a  few  tags 
of  adhesion-,  is  smooth.  The  color  varies  from  yellow  to  dark  brown,  the  dark 
areas  being  due  to  subserous  hemorrhage.  Section  shows  greatly  thickened 
walls  ami  a  practically  obliterated  lumen.  The  mucous  membrane  i-  2  or  3  mm. 
thick  and  is  sharply  outlined  from  the  surrounding  fibrous  tissue.     The  other 


Fig.  205. —  Etperplastxc  Tuberculosis  "i    thk  Appendix. 
In  the  cross-section  the  tubercle  u  as  deeply  stained  nodules 


■ 


X    i 


->",      '   s        =;  -~ 

:-'■ 

s  Hi 

t .~"'- j"^""""-- 

■ 

■s  *i' ,-~- 


- 


•v!- :;*:--:*-<*'- 


d^y 


Fig.  206. — Section    ranouGB  the  Wall  of  the  Appendix  Represented  in  Fig.  207.     Magnified  40 '!■ 

The  mucous  membrane  (a)  is  fairly  aormat,  excepting  at  ;',  where  there  are  two  small  tubercles.     The  sub- 
mucosa  Qb)  is  greatly  thickened  and  is  infiltrated  with  tuber  ■  me  of  which  contain  several  giant  cell! 

The  circular  muscular  coat  (c)  is  also  thick.  ning  giant  cell  tubercles  (AO  anil  free  giant  cells  (it).     <  'lumps 

of  round  cells  are  and  mast-cells  at     '  .     The  longitudinal  muscular  »us  fibrous 

Layei    -     are  infiltrated  with  giant  cell  tubercles. 


TUBERCULOSIS. 


339 


coats  cannot  be  differentiated  and  arc  represented  by  a  dense  fibrous  structure 
of  almost  uniform  appearance.  A  few  yellowish  foci  of  degeneration  are  seen 
in  the  subserous  tissue 

.Microscopic  Examinatio  n . — The  mucous  membrane,  as  a 
whole,  is  well  preserved,  but  shows  an  increase  of  cellular  elements  in  the  niem- 
brana  propria,  and  in  places  is  beset  with  a  few  microscopic  tubercles.  It  is 
also  unusually  vascular.  The  glandular  and  surface  epithelium  show  little 
change,  the  cells  staining  regularly  and  well.  At  one  or  two  points  where  the 
tubercles  reach  the  surface  the  epithelial  cells  are  irregular  in  form  and  cloudily 
stained ;  some  are  com-  , 

pletely  necrotic.  Lymph  /'  \ 

nodes  are  comparatively  -     ■'-    •',.--    ."  r  „  ■".  *  ,       ■     _  . 

scarce.  <  (ccasionally  the 
centre  of  a  follicle  is 
occupied  by  a  clump  of 
epithelioid  cells  some- 
times surrounding  a 
central  giant  cell.  Other 
nodes  exhibit  advanced 
fibrous  tissue  changes, 
probably  a  tubercular 
process.  The  chief  al- 
teration is  found  in  the 
submucosa  and  circular 
muscular  coats,  and 
here  the  characteristic 
picture  of  the  hyper- 
plastic tubercular  pro- 
cess is  apparent.  In 
these  layers,  which  are 
greatly  thickened,  the 
normal  structure  is  al- 
most wholly  replaced 
by     a     cellular     lil  irons 

tissue  with  a  more  or  less  plentiful  sprinkling  of  small  round,  and  plasma 
cells,  the  latter  greatly  predominating.  The  line  of  demarcation  between 
these  two  layers  is  indistinct,  owing  to  the  marked  tubercular  invasion  of 
this  region.  In  the  submucosa  the  round  cell  infiltration  is  especially  dense, 
and  tubercular  foci  are  also  most  numerous  here.  These  consist  of  aggrega- 
tions of  round  cells,  which  sometimes  surround  a  central  group  of  epithelioid 
cells,  containing  one  or  more  giant  varieties.  More  often,  however,  epithelioid 
cells  are  lacking  and  the  tubercles  consist  merely  of  lymphoid  cells,  or  of  a 
group  of  several  giant  cells  surrounded  by  small  round  cells.     At  several  points 


Fig.  207. — Higher  Magnification*  of  the  Superficial  Tubercles  Seen 
at  /  in  the  Preceding   Picture.     Magnified  250  Times. 
The  epithelium    to)   is    degenerated   where   the  tubercle  reaches  the 
surface  (6).     The  tubercles  consist  of  epitheloid  cells  (d)  surrounded  by  a 
zone  of  dense  round  cell  infiltration  («-).     The  gland  (o)  is  normal. 


340  PATHOLOGY. 

single  giant  cells  are  seen  in  the  midst  of  the  fibrous  tissue.  Many  of  these 
appear  to  be  perfectly  free  from  the  surrounding  tissue.  Epithelioid  cells 
are  scarce  throughout  the  specimen  and  typical  caseation  is  entirely  wanting. 
In  the  circular  muscular  coat  the  fibrous  tissue  proliferation  is  very  abundant, 
separating  the  individual  muscle  fibres  from  one  another.  Toward  the  inner 
margin  a  few  bundles  are  still  preserved.  Plasma  cells  and  a  (vw  lymphoid 
elements  are  distributed  generally  throughout  the  tissue  and  at  several  points 
large  mastzellen  are  seen.  Focal  tubercles  are  not  so  numerous  as  in  the  sub- 
mucosa.  The  longitudinal  muscular  coat  participates  in  the  general  thicken- 
ing, 1  nit  tn  a  less  degree  than  the  other  tissue-.  The  subserous  layer  is  thick- 
sned  ami  infiltrated  ami  contains  many  discrete  tubercles.  There  are  exten- 
sive areas  of  hemorrhage  and  some  degeneration  in  this  layer.  Sections  of  the 
small  portion  of  thi'  cecal  wall  removed,  show  tubercular  infiltration  of  the 
mucosa  ami  submucosa,  with  a  general  round  cell  infiltration  of  the  tissues. 
Many  sections  were  examined  lor  tubercle  bacilli,  but  with  negative  results. 

The  most  prominent  feature  of  this  form  of  intestinal  tuberculosis  is  the 
immense  hypertrophy  of  the  bowel  walls,  the  thickening  being  often  increased 
bv  a  fibro-adipose  deposit  in  the  subserous  layer.  The  walls  of  the  portion 
invaded  vary  from  0.5  to  :;  cm.  or  more  in  thickness,  one  case  described  by 
TiEDENAT  reaching  5  cm.  On  macroscopic  examination  it  is  often  difficult  to 
differentiate  the  tuberculous  mass  from  a  true  neoplasm.  As  a  rule,  however, 
the  mass  in  the  case  of  a  new  growth  is  more  sharply  outlined  than  in  tuber- 
cular disease.  In  the  latter  the  thickening  of  the  walls  usually  involves  the 
whole  circumference  of  the  bowel,  and,  gradually  diminishing,  imperceptibly 
merges  into  the  normal  portion.  Thus,  although  thickened  and  rigid,  the 
normal  coj  tour  of  the  intestinal  tube  is  generally  preserved.  Sometimes, 
however,  cicatricial  contractions  may  produce  various  irregularities  in  the  form 
of  the  mass,  and  in  a  case  described  by  RoUTIER  the  growth  was  limited  to  the 
posterior  cecal  wall.  Narrowing  of  the  lumen  of  the  bowel  or  actual  stenosis 
is  commonly  found  and.  as  a  rule,  is  due  to  the  gradual  encroachment  of  the 
hypertrophied  walls,  involving  the  entire  portion  affected  by  the  disease.  Cica- 
trization of  ulcerated  areas  may  also  produce  areas  of  stenosis,  hut  is  less  com- 
mon in  this  form  of  tuberculosis  than  in  the  ordinary  ulcerative  variety.  The 
characteristic  polypoid  masses  found  in  the  cecum  and  in  other  portions  of  the 
direct  intestinal  canal  may  aid  in  the  formation  of  .strictures.  This  condition 
has  not  been  described  in  connection  with  the  appendix.  The  cut  surface  of 
the  mass  presents  a  fairly  uniform,  fibrillated  structure,  which  may  hear  a 
striking  resemblance  to  a  sarcomatous  growth.  Generally,  however,  unlike 
tissues  invaded  by  a  new  growth,  the  different  layers  are  more  or  less  clearly 
defined.  Yellowish  foci  of  degeneration  are  occasionally  seen  and.  as  already 
mentioned,  masses  of  adipose  tissue  are  found  in  the  outer  coats.  Microscopic 
examination  reveals  a  picture  which,  though  varying  in  many  ways,  is  perfectly 
characteristic.     The  most  conspicuous  feature  is  the  general  fibrous  prolifera- 


TUBERCULOSIS.  341 

tion  affecting  all  the  tissues,  but  most  pronounced  in  the  submucosa.  There 
is  an  abundant  formation  of  oval  and  spindle-shaped  connective  tissue  cells, 
also  much  fibrillated  and  homogeneous  intercellular  substance.  Distributed 
throughout  the  tissue  generally,  but  in  varying  numbers  and  often  in  clumps, 
are  numerous  lymphoid  and  plasma  cells.  In  the  specimen  examined  by  my- 
self, plasma  cells  were  greatly  in  excess  in  the  diffuse  infiltration,  while  lymph- 
did  cells  predominated  in  the  focal  tubercles.  The  plasma  cells  were  mostly 
of  the  small  variety,  but  large  forms  also  were  present.  Many  showed  active 
mitosis,  or  contained  double  nuclei.  The  transformation  of  these  cells  into 
connective  tissue  cells  could  not  be  definitely  determined.  A  few  mastzellen 
and  occasional  eosinophiles  were  present  in  the  submucous  and  circular  mus- 
cular coats. 

Microscopic  tubercles  are  usually  found  in  some  places,  particularly  in  the 
mucosa  and  submucosa,  but  are  not  numerous.  They  may  have  the  typical 
structure,  consisting  of  a  central  giant  cell  surrounded  by  epithelioid  cells  and 
an  outer  zone  of  small  round  cells,  but  more  often  there  is  merely  an  aggrega- 
tion of  lymphoid  cells,  or  giant  cells  and  lymphoid  cells.  Epithelioid  cells 
and  caseation  may  be  entirely  lacking.  In  some  instances  typical  tubercles 
are  absent,  as  in  Lartigau's  and  Pilliet's  cases.  In  Pilliet's  case  there 
was  a  general  massive  infiltration  of  embryonal  cells,  which  at  first  sight  was 
suggestive  of  a  sarcomatous  growth.  While  the  lesions  are  most  marked  in  the 
mucous  and  submucous  layers,  the  muscular  coats  participate  to  a  variable 
extent  and  the  peritoneal  coat  frequently  shows  extensive  lesions.  The  nature 
of  the  lesions  is  essentially  that  of  a  chronV  productive  inflammation  associated 
with  a  tubercular  process.  By  some  writers,  notably  Hartmann,  Pillikt. 
and  Benoit,  it  is  believed  that  secondary  infections  play  an  important  role  in 
the  production  of  the  special  lesions  found  in  this  class  of  tubercular  affection-, 
while  Itie  inclines  to  the  belief  that  the  tubercular  infection  is  engrafted  upon 
an  antecedent  inflammatory  process.  The  chronicity  of  the  process  and  its 
productive  nature  are  most  plausibly  explained  by  the  theory  of  an  infection 
with  attenuated  bacteria.  Mallort,  in  studying  the  effect  produced  on  tissues 
by  the  toxin>  secreted  by  bacteria,  showed  that  whereas  strong  toxins  cause 
degeneration  or  necrosis  of  the  cells  and  exudation,  dilute  and  weak  toxins  induce 
proliferation  and  phagocytosis.  The  paucity  in  number  of  the  organisms  usually 
present  may  have  some  influence  upon  the  nature  of  the  process,  but  is  not  in 
itself  a  sufficient  explanation,  for  in  the  cases  described  by  Lartigau,  and  by 
CAUSSADE   and   Charrier,   tubercle  bacilli   were   very   numerous. 

How  the  attenuation  is  brought  about  is  not  clearly  understood.  Hart- 
mann  and  Pillikt  consider  the  action  of  other  organisms  an  important  factor, 
but,  on  the  other  hand.  Ramond  and  Ravaut  have  demonstrated  that,  while 
in  culture  tubes  the  growth  of  tubercle  bacilli  is  arrested  when  associated  with 
other  microbes,  in  the  living  organism,  when  other  bacteria  are  present,  tubercu- 
losis develops  much  more  rapidly.     This  result   they  believe  to  be  due  to  the 


342  PATHOLOGY. 

impairmenl  of  the  resistance  of  the  tissues  and  not  to  the  direct  action  of  the 
other  bacteria.  Cbowder  advances  the  reasonable  view  that  individual  re- 
sistance is  probably  an  important  factor  in  limiting  the  action  and  causing 
the  attenuation  of  the  bacillus:  "The  toxins  of  a  given  tubercle  bacillus  might 
lie  able  to  produce  only  slight  irritation  when  growing  in  the  tissues  of  one 
appendix,  thus  determining  a  conservative  process  of  hyperplasia,  while  in 
another  they  mighl  produce  rapid  necrosis."  Jn  support  of  this  view  he  directs 
attention  to  the  fact  that  in  cases  of  hyperplastic  tuberculosis  of  the  cecum 
it  is  unusual  to  find  any  rapidly  progressive  or  destructive  lesion  in  other  parts 
of  the  body,  whereas  an  old  healed  or  latent  t uberculosis  of  the  lung  often  exists. 


ACTINOMYCOSIS. 

Actinomycosis,  like  intestinal  tuberculosis,  shows  a  special  predilection  for 
the  cecal  region,  hut,  unlike  the  tubercle  bacillus,  which  in  most  instances  pri- 
marily attacks  the  cecum,  the  actinoinyces  more  frequently  enters  the  vermi- 
form appendix,  and  from  there  invades  the  tissues.  It  is  generally  considered 
that  the  appendix  is  the  chief  portal  of  entry  for  the  infective  agent  in  abdom- 
inal actinomycosis.  While  in  many  cases  the  parasite  cannot  he  demonstrated 
in  the  appendix,  the  relation  of  the  organ  to  the  actinomycotic  mass  and  its 
diseased  condition  permit  no  question  as  to  the  primary  location  of  the  in- 
fection. 

The  actinoinyces  or  ray  fungus  is  classed  among  the  bac- 
teria of  the  genus  streptot  hrix.  The  colonies  appear  in  the  form 
of  opaque,  gelatinous  granules,  about  0.5  nun.  to  2  nun.  in  diameter.  They 
are  usually  of  a  sulphur  or  orange-yellow  color,  hut  are  sometimes  gray  or 
yellowish-green.  Histologically  the  colonies  consist  of  several  dif- 
ferent elements.  In  the  centre  is  a  granular  material  anil  bodies  resembling 
cocci  or  spores,  while  extending  from  the  centre  there  is  a  dense  net- 
work of  fine  filaments,  from  which  filamentous  branching  threads  radiate 
outward.  These  threads  usually  present  characteristic  club-like  terminations, 
but  in  the  human  form  of  the  disease  the  clubs  are  often  inconspicuous.  WEIGERT 
has  shown  that  the  clubs  may  become  indistinct,  or  even  disappear,  in  conse- 
quence of  post-mortem  changes. 

Pathological  Changes  in  the  Tissues.  —  In  the  purest 
form  of  actinomycotic  infection  in  man  the  reaction  on  the  part  of  the  tissues 
is  merely  a  chronic,  productive,  inflammatory  process,  but,  as  in  most  cases  the 
infective  agent  enters  through  a  cavity  which  is  beset  with  bacteria,  suppura- 
tion is  an  almost  constant  accompaniment  of  actinomycosis.  The  granulation 
tissue  is  generally  bathed  in  a  scanty,  thin,  puriform  fluid,  which,  owing  to 
hemorrhages,  is  often  of  a  brownish  color;  but  according  to  Partsch,  unless 
secondary  infection  with  the  ordinary  pyogenic  organisms  occurs,  pus  is  not 
found.     Israel,  however,  states  that  in  man  the  actinoinyces  induces  suppura- 


ACTINOMYCOSIS.  343 

tion,  a  view  also  held  by  Czkrxy  and  Heddaeus.  In  an  early  state  the  prod- 
ucts of  the  infection  appear  as  a  brawny,  pseudo-fluctuant,  tumor  mass.  The 
tendency  of  the  tissue  to  undergo  fatty  degeneration  and  its  disposition  toward 
hemorrhages  result  in  the  formation  of  irregular  spaces,  which  are  lined  with 
soft,  yellow  or  reddish  granulations  and  contain  a  sparse  amount  of  thin  fluid, 
in  which  the  characteristic  bodies  float.  Some  writers  claim  that  this  material 
emits  a  characteristic  odor,  but  Partsch  and  others  consider  that  the  odor 
is  due  to  the  presence  of  other  intestinal  bacteria.  The  disease  is  essentially 
chronic,  but  after  a  longer  or  shorter  period  it  ceases  to  be  localized  and  invades 
the  neighboring  structures,  forming  indurated,  connective  tissue  masses  accom- 
panied with  a  diffuse  edematous  infiltration  of  the  surrounding  tissues.  Softer 
areas  are  found  here  and  there,  but  are  not  numerous.  This  dense  scar-like 
connective  tissue  formation  is  characteristic  of  the  activities  of  the  actinomyces, 
and  in  the  chronic  form  is  never  absent.  It  may  reach  such  dimensions  that 
a  true  tumor  is  simulated.  The  inflammatory  products  embed  the  nerves, 
infiltrate  and  separate  the  muscle  bundles,  and  invade  the  walls  of  the  blood- 
vessels. In  the  dense  new  formation,  as  already  mentioned,  there  are  sparsely 
distributed  softer  areas,  also  spaces  of  variable  size,  varying  from  slight  chinks 
to  cavities  as  large  as  a  fist.  Microscopic  examination  reveals  a  dense  fibrous 
tissue  proliferation  invading  and  compressing  the  normal  tissue.  Plere  and 
there  aggregations  of  small  round  cells,  sometimes  polymorpho-nuclear  leuco- 
cytes, are  noticed.  These  correspond  to  the  softened  areas  observed  in  the 
gross  specimen  and  also  form  the  chief  part  of  the  granulations  lining  the  cavities. 
As  noted  by  Marchand,  occasional  giant  cells  are  found.  According  to  Partsch 
it  is  only  in  these  areas  of  round  cell  infiltration  that  the  actinomyces  are  found, 
and  often  it  is  necessary  to  examine  several  sections  in  order  to  demonstrate 
the  cause  of  the  disease.  The  demonstration  of  the  ray  fungus  is,  however, 
absolutely  indispensable  to  a  diagnosis.  The  intestinal  mucous  membrane 
usually  presents  small  areas  of  ulceration,  which  are  the  result  of  the  breaking- 
down  of  small  nodules.  The  crater  of  the  ulcer  consists  of  the  denuded  muscle. 
The  mucosa  generally  is  deeply  stained  with  extravasated  blood,  especially 
in  the  vicinity  of  ulcers,  and  as  these  become  healed  a  blackish  pigmented  cica- 
trix remains.  As  the  infection  soon  penetrates  the  intestinal  walls  there  is  a 
reaction  on  the  part  of  the  peritoneum,  the  intestinal  coils  becoming  adherent 
to  the  neighboring  structures  and  to  one  another.  These  adhesions  then  be- 
come infiltrated  with  the  hyperplastic  inflammatory  products,  the  character- 
istic softening  and   cavity  formation   taking  place  later. 

The  disease  advances  in  all  directions,  and  usually  penetrates  the  abdominal 
fascia,  with  subsequent  infiltration  of  the  parietes.  which  become  edematous 
and  indurated.  Finally,  necrosis  takes  place,  and  extending  to  the  skin  surface 
produces  fistulous  openings,  several  of  which  usually  appear  almost  simul- 
taneously. Cases  of  perforation  of  the  bladder  and  rectum  have  also  been 
reported,  and    rupture  of  tin1  diaphragm  is  a  common  event.     The    peculiar 


:;il  PATHOLOGY. 

soft  yellow  or  reddish  granulations  lining  these  sinuses  differentiate  them  from 
simple  inflammatory  conditions.  The  infection  extends  mainly  l>y  direct  con- 
tinuity, invading  all  structures,  but  is  also  propagated  by  way  of  the  blood- 
vessels and  may  develop  a<  many  distant  points,  as  in  other  metastatic 
inner--,-.  Dissemination  by  way  of  the  lymph  circulation  has  never  been 
observed.  Infection  of  the  lymph  glands  sometimes  occurs,  bul  is  due  to  their 
direct  invasion  by  continuity.  As  the  morbid  process  advances,  the  older 
portions  may  become  partly  absorbed  and  in  part  reduced  to  a  few  thick  bands 

car-like  tissue.  Tims,  a  large  mass  may  gradually  subside  while  an  active 
process  is  advancing  in  other  areas.  In  other  instances,  alter  free  incision 
the  granulation  tissue  gradually  undergoes  complete  resolution.  When  the 
actinomycotic  process  is  associated  with  an  infection  by  the  ordinary  pyogenic 
organisms,  suppurating  foci  are  found  here  and  there,  and  true  abscesses  some- 
times form.     The  patient  may  ultimately  succumb  to  the  secondary  infection. 

In  the  cases  originating  in  the  appendix  various  conditions  have  been  found 
in  this  organ.  In  only  a  lew  instances,  notably  the  cases  of  Helferich,  [llich, 
and  Langhans,  and  in  my  own,  has  the  specific  process  and  parasite  been  ob- 
served in  the  appendix  itself.  In  many  cases  the  appendix  merely  shows  a 
simple  perforative  inflammation.    The  large  proportion  of  cases  in  which  a 

fecal  i cretion  is  funned  suggests  the  possibility  that  the  foreign  body  may 

play  an  important  r61e  in  the  development  of  the  disease,  either  by  determining 
a  rupture,  or  by  causing  pressure  necrosis,  and  thus  facilitating  the  invasion 
of  the  appendical  walls.  In  a  case  described  by  Illich,  a  husk  of  corn  was 
found  with  the  actinomyces  in  the  appendix;  and  in  Ammentorp's  case  a  barley 
husk  was  found  with  the  actinomyces  in  an  abscess  cavity.  The  appendical 
walN  are  often  not  invaded  by  the  parasite,  which,  having  lodged  in  the  canal. 
escapes  through  a  perforation,  not  due  to  its  activities,  and  excite-  the  charac- 
teristic reaction  in  the  surrounding  tissues.  Again,  there  are  cases  in  which 
the  appendix  has  evidently  been  the  seat  of  an  old  actinomycotic  infection, 
and  partial  or  complete  repair  has  supervened.  Such  an  appendix  may  appear 
thickened  and  rigid,  its  condition  resembling  a  chronic  obliterative  inflamma- 
tion. The  interior  may  show  a  narrowed  or  stenosed  lumen  and  pigmented 
scars  representing  healed  ulcerations.  The  case  which  has  recently  come  under 
my  personal  observation  is  a  good  example  of  this  condition.  In  this  instance 
the  etiological  relation  of  the  almost  obliterated  appendix  to  the  actinomycotic 
process  was  not  clear,  and  the  possibility  of  the  primarily  cecal  origin  of  the 
disease  was  entertained.  Histological  examination,  however,  revealed  very 
clearly  the  appendical  origin  of  the  trouble.  For  the  clinical  history  of  this 
case  see  Chap.  XXXII.  page  768.    The  chief  points  of  interest  in  the  autopsy 

protocol  are  as  follows: 

A  n  a  t  o  m  i  c  a  1  Dia  ,Lr  nosi  s. — Actinomycosis  of  the  liver,  spleen,  and 
lungs;  acute  actinomycotic  pleuritis  with  effusion;  healed  actinomycosis  of 
the  appendix  and  anterior  abdominal  wall;    chronic  peritonitis. 


ACTINOMYCOSIS. 


:;i:. 


The  omentum  covers  the  small  intestine,  which  is  adherent  to  the  anterior 
abdominal  wall.  There  are  a  few  adhesions  between  the  uterus  and  sigmoid 
flexure  to  the  small  intestine.  The  liver  is  attached  to  the  diaphragm  by  ad- 
hesions of  a  somewhal  fibrous  character.  On  attempting  to  separate  the  right 
lobe  from  the  diaphragm  an  abscess  cavity,  8  cm.  in  diameter,  is  broken  into. 


.11  of 
5  nowing 


I 


Section  through  A  Section  through  J 


Fig.  208. — Actinomycosis  of  the  Appendix. 
Posterior  view  of  the  ileocecal  apparatus,  showing  the  appendix  enclosed  in  a  dense  mass  of  inflammatory 
tissue  which  is  riddled  with  abscess  fuel.  The  appendix  appear,-  thickened  and  rigid  and  al»>m  itfi  middle  is 
strictured  and  bent  at  a  slight  angle  by  a  band  of  adhesions.  Sections  through  the  distal  and  proximal  ends 
show  apparent  obliteration  of  the  lumen.  In  Section  B,  a  minute  abscess  focus  is  visible  in  the  external  tunic 
of  the  appendix.     (Autopsy,  No.  2165.) 


Intestine  s. — The  serous  surface  is  pale  throughout.  In  the  region  of 
the  appendix  several  coils  are  adherent  to  the  abdominal  walls,  to  the  right 
round  ligament,  and,  slightly,  to  the  cecum.  The  appendix  can  be  felt  as  a 
firm  cylindrical  mass  lying  under  the  ileum,  where  it  is  embedded  in  a  mass 


:m 


PATHOLOGY. 


.  - .  v**.V 


*'/ 


^/;< 


j*  v./ 


Si  i 


... 


SSr-i*-.-.* '  **^y  .  ••• 


of  dense  connective  tissue.  In  enucleating  the  appendix,  a  sieve-like  abscess 
focus  is  found  in  the  appendico-cecal  angle  infiltrating  the  inflammatory  mass. 
The  appendix  is  .">..">  cm.  long,  its  walls  thickened,  and  its  lumen  almost  obliter- 
ated.    The  proximal  end  forms  a  dense  knob-like  protuberance  into  the  cecum. 

The  mucosa  covering 
this  inverted  portion  of 
the  appendix  and  the 
cecal  wall  arc  both 
stained  a  dark  reddish- 
brown.  Otherwise,  the 
intestinal  mucous  mem- 
brane is  perfectly  nor- 
mal.     (See   Fig.   208.) 

Microscopical 
E  xamination. 
The  peri-appendical 
mass  presents  the  usual 
hyperplastic  inflamma 
tory  tissue,  consisting 
of  an  abundant  fibril 
lated  or  homogeneous 
ground  substance  with 
fairly  numerous,  fusi- 
form, connective  tissue 
cells.  A  few  lymphoid 
and  plasma  cells  are 
distributed  throughout 
this  tissue,  occasionally 
forming  clumps,  but  in 
the  granulation  tissue 
lining  the  abscesses, 
pol  vmorpho- nuclear 
leucocytes  predominate 
and  are  also  present 
whenever   the    parasite 

is    found.       The    appen- 
dix  shows    the   changes 
characteristic  of  chronic 
obliterative     inflamma- 
tion.  (See  Fig.  209.)  Its 
walls,  particularly  the  submucosa,  are  thickened  and  fibrous.   The  canal  is  reduced 
to  a  hair's  breadth,  and  is  lined  with  atrophic  mucous  membrane,  which  contains 
a  few  shallow  glands,  but  no  lymph  follicles.     At  one  point,  near  the  middle  of 


Fig.  JOCt.  -Actinomycosis  of  the  Appendix.  Magnified  75  Times. 
\  section  through  the  median  portion  of  the  appendix  showing  a  granu- 
lating cavity  occupying  the  site  of  the  appendical  canal.  The  cavity  a  con- 
of  mucus,  round  cells,  a  few  polymorpho-nuclear  leucocytes 
arid  cellular  detritus.  The  lining  of  the  cavity  It  is  composed  "f  typical 
actinomycotic  granulation,  the  inner  portion  consisting  almost  wholly  of 
round  cells,  while  farther  out  there  are  abundant  fusiform  connective  ti--ue 
cells,  (liant  cells  are  seen  at  d.  The  submucosa,  r,  is  thickened  and 
filir>.u-.  and  its  blood-vessels  highly  sclerotic,  d  indicate-  a  segment  of  the 
circular  muscular  coat. 


TYPHOID    FEVER. 


347 


the  appendix,  the  mucosa  has  been  replaced  by  actinomycotic  granulations, 
consisting  chiefly  of  round  cells  and  containing  two  or  three  giant  forms. 
In  one  place  there  is  an  area  of  polymorpho-nuclear  infiltration  between  the 
subserous  and  internal  muscular  coats,  and  at  this  point  the  actinomyces 
is  found  (see  Fig.  210).  It  is  also  present  in  the  peri-appendical  abscess. 
The  cecal  mucosa  is  hemorrhagic  and  shows  slight  degenerative  changes. 
The  peritoneal  surface  is  involved  in  the  actinomycotic  mass  which  also  sur- 
rounds the  appendix. 


Fig.  210. — Actinomycosis  of  the  Appendix.     Enlarged  420  Times. 

From  a  section  through  the  wall  of  the  appendix  at  the  junction  of  the  submucosa  (<0  and  the  circular  muscular 

coat  (6).     (rf)  indicates  parasite  colonies  in  the  midst  of  an  abundant  leucocytic  infiltration  (c). 


TYPHOID  FEVER. 
From  the  standpoint  of  pathological  anatomy  the  affections  of  the  appendix 
arising  during  the  course  of  typhoid  fever  may  be  divided  into  three  classes 
of  cases: 

1.  Those  in  which  the  appendix  participates  in  the  typhoid  lesions. 

2.  Those  in  which  a  secondary  infection  with  pyogenic  organisms  is  en- 
grafted upon  the  typhoid  affection. 

3.  Those  in  which  a  simple  appendicitis  develops,  the  appendix  not  being 
involved  in  the  typhoid  infection.  In  these  last  cases,  however,  it  is  probable 
that   the  attack  is  often   precipitated  by   the  congestion  which  accompanies 


348  PATHOLOGY. 

tlir  typhoid  infection,  although  there  may  be  no  specific  typhoidal  lesions  in 
the  appendix. 

It  is  generally  stated  thai  the  appendix  is  involved  in  about  one-third  of 
all  cases  of  typhoid  fever,  and  that  of  the  perforative  cases  there  is  a  perfora- 
tion of  the  appendix  in  about  .5  per  cent.  Some  statistics  give  a  higher  per- 
centage, while  others  again  are  much  lower.  It  is  not  explained,  however, 
whether  these  are  coincident  attacks  of  simple  appendicitis  or  are  true  typhoid 
lesions.  ().  HOP]  i  \n  w  BEN,  in  a  series  of  thirty  autopsies  upon  typhoid  sub- 
jects, found  some  alteration  of  the  appendix  in  all,  the  lesions  ranging  from  a 
slight  hyperemia  to  diffuse  inflammation  associated  with  ulceration.  The 
ulceration  was  always  superficial. 

Cases  in  which  the  Appendix  Participates  in  the  Typhoid  Lesions. — 
These  cases  vary  greatly  in  the  extent  and  severity  of  the  lesions.  In  the  ma- 
jority of  instances  there  is  merely  a  slight  congestion  of  the  blood-vessels,  espe- 
cially in  the  serous  ami  mucous  coat-.  In  other  cases  the  whole  appendix  is 
swollen  ami  turgid  and  its  lumen  is  practically  obliterated  by  the  swollen  mucosa. 
The  appendix  shown  in  Fig.  4.  Plate  I.  was  removed  at  operation  on  the  fifteenth 
day  of  the  typhoid  attack.  It  was  greatly  swollen,  tense,  ami  of  a  uniform 
brighl  red  color.      On  cross-section  the  muscular  Coats  appeared  to  lie  distended 

by  the  greatly  swollen  mucous  and  submucous  layers,  which  also  completely 
filled  the  canal.  Histological  examination  revealed  typical  typhoidal  changes, 
without  necrosis.  In  cases  of  this  kind  there  are  frequently  slight  extravasa- 
tions of  blood  into  the  mucosa,  and  even  into  the  deeper  tissues.  The  lymph 
nodes  may  he  very  prominent,  and  they  sometimes  show  yellow  necrotic  foci. 
In  other  cases,  again,  more  or  less  extensive  ulcerations  are  found,  sometimes 
merely  involving  the  surface  of  the  mucosa,  and  sometimes  extending  into  the 
submucosa  ami  even  destroying  the  muscular  coats.  The  ulcers  may  he  of 
pin-head  size,  arising  from  degenerated  lymph  nodes  (as  in  one  case  of  Mac- 
MoNAGLE's  '.  "i'  they  may  extend  superficially  over  the  greater  part  of  the  mucous 
membrane.  As  would  naturally  he  supposed,  the  most  pronounced  changes 
are  found  during  the  acute  stage  of  the  typhoid  infection.  Hopfenhatjsen 
found  the  maximum  lesions  during  the  first  three  weeks;  and  later,  as  in  the 
case  of  the  rest  of  the  intestine,  the  inflammation  was  less  evident. 

The  c  h  a  i'  a  c  t  er  is  t  i  e  typhoidal  les  i  o  n  s  found  in  these 
cases  clearly  differentiate  them  from  the  cases  complicated  with  s  e  C- 
o  n  d  a  r  y  infections,  and  from  s  i  m  p  1  e  a  p  p  endicitis.  Ac- 
cording to  Mallory,  the  early  changes  are  proliferative  in  character  and  con- 
sist in  a  hyperplasia  and  hypertrophy  of  the  reticular  cells  of  the  lymph  nodes, 
also  of  the  endothelial  lining  of  the  lymph  spaces  of  all  the  tissues,  hut  particu- 
larly of  the  membrana  propria  of  the  mucosa.  The  endothelium  of  the  lymph 
vessels,  capillaries,  and  veins,  and  to  a  less  extent  the  arteries,  also  proliferates. 
These  cells  become  epithelial  in  character  and  possess,  to  a  marked  degree, 
the  property  of  phagocytosis.     These  large  cells  were  also  described  by  Bill- 


TYPHOID    FEVER.  349 

roth,  by  Grohe,  and  by  others.  Accompanying  these  changes  there  is  a  pro- 
liferation of  lymphoid  and  plasma  cells  and  active  mitosis  is  noticed  in  the 
glandular  epithelium.  In  mild  cases  the  phagocytic  cells  rapidly  undergo  fatty 
degeneration  and  disappear,  the  tissues  soon  regaining  their  normal  condition. 
The  degeneration  of  the  proliferated  endothelial  cells  in  the  vessel  walls  fre- 
quently forms  the  starting-point  of  a  thrombotic  process  (see  Pig.  211).  In 
severe  cases  tissue  necrosis  usually  supervenes,  and  is  explained  by  Mallory 
as  due  to  thrombosis  of  the  lymph  vessels  and  veins.  In  consequence  of  the 
necrosis  there  is  an  inflammatory  exudation  which  consists  almost  wholly  of 
serum  with  very  abundant  fibrin.  This  exudation  collects  chiefly  in  the  sub- 
mucosa.  Polymorpho-nuclear  leucocytes  are  not  numerous  and  are  often  absent 
in  small  foci ;  in  the  larger  foci  they 

are  usually  present  in  considerable  b 

numbers,  especially  on  the  surface    «v*%*  J*k  /f^    '^X^  % 
where  various  int 
are  invading  the  ne 

A  beautiful  ex; 
ulceration  of  the  a 
furnished  me  by 
of  Harvard  (Figs.  I'll',  2^ 

With   the   low    magnification  the    *%*  \%    ,a    •  ,*      *"'-|^,  m    b-  -<».-. 

entire  thickness  of  the  appendix  '{f (••%*  |f^^»'  •»£'*'  '*'&£*&& &, 
wall  is  seen.  The  muscular  and  ^jf'SS*-  St*?*  £#' S*  •  $**&•*£* 
subperitoneal  layers  are  only  ^  VSRjv-* ¥B»J^S? *••*••  «*.-' 
ightlv    altered,    but    the 


mucosa  is  immensely  thickened 
and  densely  infiltrated,  while  the 
mucous  membrane  is  completers' 

1  *  Fig.  211. — Thrombosed  \  essblin  the  Appendix  IN  A  <  ask 

necrotic.     On  the  surface  there  is  of  typhoid  fever,    magnified  330  Times. 

a  thick   layer  Of    fibrin    containing  "•  The  endothelial  lining  of  the  vessel;  6.  the  thrombus, 

containing  large  endothehoul   cells  (c).  some  of    which  are 

leucocytes    and  cellular  detritus,        phagocytic.    (Surg.  Path.,  No.  3194.) 

and    in    the    underlying   necrotic 

tissue  polymorpho-nuclear  leucocytes  are  plentiful.     Beyond  the  necrosis  the 

polymorpho-nuclear   invasion    ceases  and  the  infiltrate  is  wholly  made  up  of 

lymphoid  and  plasma  cells  and  abundant  large  phagocytic  cells. 

Restitution  may  follow  extensive  necrosis,  but,  as  a  rule,  large  areas  of  necro- 
sis are  repaired  by  a  connective  tissue  formation  which  is  ultimately  converted 
into  scar  tissue. 

In  one  of  my  cases  (Fig.  215),  obtained  at  autopsy  on  a  woman  who  had 
died  in  the  eleventh  week  of  the  typhoid  infection,  the  appendix,  which  was 
11  cm.  long,  was  slightly  distended  in  its  distal  portion  and  somewhat  injected. 
Its  walls  were  not  thickened.  The  mucous  membrane,  which  for  the  most 
part  was  pale  and  smooth,  presented  several  depressed  injected  areas  represent- 


350 


l'vrnni.oaY. 


Lng  healing  ulcers,  also  small  superfici. 
the  canal,  for  a  distance  of  aboul  •'!  cm., 
lucent    material,  which   on   one 
sitle  was  firmly  attached  to  the 

appendical  wall  and  could  not 
he  removed  without  tearing  the 
tissue.  On  microscopic  exam- 
ination (Fig.  216)  the  muscular 


d  ulcers;   while  the  lowest  portion  of 

was  filled  with  a  tough,  grayish,  trans- 


->c 


Fig.  212. — Typhoid  Ulceration  of  the  Ap- 
pendix. Magnified  25 Times. 
a.  Fibrinous  exuilate;  b,  mucosa  and 
Bllbmucosa,  densely  infiltrated  and  necrotic  in 
the  superficial  portion;  /,  degenerated  vessels 
containing  leucocytes;  r.  circular  muscular 
coat;  '/,  longitudinal  muscular  coat;  c,  peri- 
toneum.   (Specimen  from  11.  A.  Christian.) 


•    ■  '.  -.***«.,>     "He* 


Fio.  213. — Section  from  Base  of  Ulcer  Seen  in 
Fig.  212.     Magnii  hi.  :;oo  Times. 

a.   Necrotic  tissue;  b,  large  phagocytic  cells  infiltrat- 
ing the  submucosa. 


••• 


'   'I. 


:■:>* 


f 


4 


(g 


.7  BiieA'w     , 


Fio.  214. — Higher  Magnification  (360  Times)  of 
Large  Phagocytes  (a). 


and  submucous  layers  appeared  nor- 
mal. The  deeper  portion  of  the 
mucosa  also  was  almost  normal,  hut 
the  superficial  portion  in  places  was 
necrotic.  Sometimes  only  the  epithelium  was  involved  in  the  necrosis;  at 
other  times  the  superficial  portions  of  the  glands  and  membrana  propria.     The 


TYPHOID    FEVER. 


351 


exudation  covering  these  necrotic  areas  consisted  of  fibrin,  mucus,  and  a  few 
cellular  elements,  while  a  few  small  blood-vessels  from  the  mucosa  were  I  race- 
able  a  short  distance  into  it.  In  this  case  the  healing  process  had  apparently 
been  arrested  by  the  exceedingly  low  degree  of  vitality  possessed  by  the 
patient. 

Typhoid  Lesions  in  the  Appendix  Complicated  with  Secondary  Inva- 
sion of  Other  Bacteria. — These  cases  probably 
comprise  a  large  proportion  of  those  in  which 
symptoms  of  an  acute  perforative  appendicitis 
occurs  early  in  the  course  of  the  typhoid  infection. 
In  the  gross  specimen  they  cannot  be  differen- 
tiated from  the  simple  acute  appendicitides,  but 
microscopic  examination  reveals  the  characteristic 


tier 


■cm 


■  «- 


:"•*>, 


Fig.  215. — Typhoid  Appendix, 
Eleventh  Week, 
a.  Healed  ulcers;  b,  more  recent 
superficial  ulcers  covered  with  a  fibri- 
nous exudate;  c,  mass  of  partially 
Organized  exudate.  (Autopsy,  Nov. 
L3,  190  J.) 


Fig.    216. — Typhoid    Appendix.    Magnified    120    Times.      Section 

from  Fig.  215. 

a,  Fibrinous  exudate  covering    the  degenerated  surface  of  the  mucosa 

(6);  c,  normal  submucosa. 


typhoid  lesions  with  the  superimposed  purulent  inflammation.  Two  very 
interesting  cases  have  been  furnished  by  MacMonagle.    Both  appendices  were 

removed  at  operation  at  the  end  of  the  second  week  of  the  typhoid  infection, 
but  while  one  shows  a  mixed  infection,  the  other  shows  a  simple  appendicitis. 
The  first  appendix  is  9  cm.  long,  7  to  10  mm.  in  diameter,  a  slight  constriction 


352  PATHOLOGY. 

dividing  the  thickened  middle  portion  into  two  parts.  The  surface  is  deeply 
injected  and  hemorrhagic,  one  point  showing  beginning  necrosis.  There  are 
adhesions  aboul  the  appendix.  The  mucous  membrane  lining  the  proximal 
third  i>  swollen  but  smooth;  farther  out  it  is  ulcerated,  the  necrosis  extend- 
ing at  one  point  to  the  peritoneal  surface.  Microscopical  examination  of  the 
cecal  portion  shows  that  the  swelling  of  the  mucosa  i-  produced  by  the  pres- 
ence of  an  abundant  infiltrate,  chiefly  consisting  of  large  phagocytic  cells 
which  are  seen  in  the  lymph  nodes  and  stroma.  The  mucous  membrane  of 
the  rest  of  the  appendix  is  studded  with  pin-head  ulcers,  almost  all  of  which 
are  situated  in  the  chinks  between  the  folds,  ami  apparently  have  been  pro- 
duced by  necrosis  of  the  lymphoid  follicles.  This  portion  of  the  appendix  also 
-hows  a  diffuse  purulent  inflammatory  process. 

Simple  Appendicitis  Arising  During  the  Course  of  Typhoid  Fever. — 
In  the  reported  cases  there  are  no  data  given  from  which  to  determine  the 
frequency  of  this  class  of  cases,  hut  ii  priori,  we  should  not  expect  it  to  he  a  rare 
event.  In  particular,  where  there  are  concretions,  kinks,  or  stenoses  conse- 
quent upon  an  old  inflammation,  it  seems  very  probable  that  the  hyperemia 
of  the  appendix  accompanying  the  typhoid  infection  would  have  an  important 
influence  in  precipitating  an  acute  appendicitis.  Histological  examination  of 
the  appendix  in  such  a  case  shows  a  simple  inflammatory  reaction  and  nothing 
suggestive  of  a  typhoid  infection.  The  second  case  sent  by  MacMonagle 
appears  to  be  of  this  nature.  The  appendix  is  5  cm.  long.  7  mm.  in 
diameter,  with  a  slightly  bulbous  tip.  The  surface  is  injected  and  hemor- 
rhagic and  in  places  covered  with  a  fibrinous  exudate.  The  cecal  half  of  the 
canal  is  distended  with  a  concretion  1  X  0.6  cm.  Beyond  this  the  mucosa 
is  completely  necrotic.  Histological  examination  shows  complete  necrosis  of 
the  mucous  membrane  and  purulent  inflammation  of  all  the  tissues,  involv- 
ing the  portion  of  the  appendix  distal  to  the  part  containing  the  concretion. 
The  mucosa  of  the  latter  area  is  degenerated,  but  the  other  layers,  apart 
from  being;  thinned  out,  are  not  affected.  There  is  no  appearance  of  typhoid 
lesions. 

AMEBIC  DYSENTERY. 

The  Amoeba  coli  was  discovered  in  the  stools  of  infants  and  cholera  patients 
by  Sambl  and  Cunningham,  but  Loses  first  accurately  described  the  disease 
in  1S75.  In  America  the  Amoeba  was  first  found  by  Oslkk,  in  1S!K).  This 
organism  belongs  to  the  class. Rhizopoda  of  the  Protozoa.  It  is  an  actively 
amoeboid,  unicellular  organism,  and  varies  in  size  between  8  and  37  micron-. 
averaging  20  microns.  It  consists  of  an  inner  granular  portion,  the  endosarc; 
and  an  outer  hyaline  layer,  the  ectosarc.  The  nucleus,  about  16  microns,  is 
situated  near  the  margin  of  the  endosarc  and  in  stained  specimens  a  nucleolus 
is  seen.  There  are  often  several  vacuoles,  and  frequently  foreign  elements, 
especially  red  blood  corpuscles,  in  the  endosarc. 


AMCEBIC    DYSENTERY. 


353 


Aii  admirable  description  of  the  lesions  produced  in  the  infected  tissues 
is  given  by  L.  Rogers,  of  the  Indian  Medical  service.  These,  at  first,  are  small. 
pin-point  elevations,  reddish,  with  a  yellowish  centre.  The  earliest  forms 
usually  found  are  circular  or  oval  ulcers,  ranging  from  the  size  of  a  pea  to  an 
inch  in  length,  the  long  axis  of  the  ulcer  running  at  right  angles  to  the  axis  of 
the  bowel.     They  appear  as  raised  patches  with  well-defined  thickened  margins, 


Fig.  217. — AMrFmc  Dysentery*. 
The  appendix  bent  at  an  acute  angle  and  held  in  this  position  by  firm  adhesions.     Almost  complete  obstruc- 
tion of  the  canal  at   the  angle,  and  the  distal  portion  distended  with  yellowish  gelatinous  material.       (Autopsy 
No.  2165.) 


often  surrounded  by  a  zone  of  congestion.  The  crater  of  the  ulcer  is  filled 
with  a  characteristic,  yellow,  gelatinous  material.  A  striking  feature  (if  the 
disease  at  this  period  is  the  healthiness  of  the  bowel  immediately  beyond  the 
ulcerated  area.  Later  the  ulcers  lose  their  round  or  oval  form  and  appear 
as  long  irregular  ulcers,  extending  along  the  folds  of  mucosa,  or  as  greatly  thick- 
23 


;;;,  I  pathology. 

ened  raised  patches  with  lighl  yellow  or  tawny  ragged  sloughs.  Occasionally 
black  sloughs  form.  In  very  chronic  cases  there  may  be  some  thickening  of 
the  bowel  wall.  Resolution  proceeds  by  the  gradual  disappearance  of  the 
gelatinous  material,  the  base  of  the  ulcer  becomes  depressed  and  contracted, 
causing  a  puckering  of  I  be  still  thickened  margin,  the  defecl  is  filled  in  by  granu- 
lations, and  finally  a  patch  of  scar  tissue  remains,  which  in  many  cases  is  pi<r. 
mented.  <*n  microscopic  examination  there  is  found  to  be  a  notable  absence 
of  the  products  of  purulenl  inflammation.  According  to  Fi  tcher,  polymorpho- 
nuclear leucocytes  are  seldom  found  and  never  constitute  purulenl  collections. 
The  must  striking  feature  is  the  enormous  thickening  of  the  submucous  coal, 
while,  mi  the  other  hand,  the  mucous  layer  is  hut  little  altered.  There  is,  first, 
an  infiltration  of  the  submucosa,  with  yellow  gelatinous  material;  a  portion 
of  the  overlying  mucosa  then  disappears,  probably  by  a  process  of  anemic  necro- 
sis. The  gelatinous  material  then  forms  the  floor  of  the  ulcer,  the  infiltration 
of  the  submucosa,   however,   extending  considerably  beyond   the  superficial 

denudation. 

The  lesions  are  most  marked  in  the  upper  pari  of  the  large  intestine,  and  when 
the  disease  is  slight  the  ulcers  are  usually  limited  to  the  cecum  and  ascending 
colon.  The  vermiform  appendix  is  often  severely  affected; 
just  as  in  typhoid  fever,  perforation  of  the  ulcer  may  occur.      In  a  case  illustrated 

in  Rogers' article,  perforation  of  the  appendix  caused  fatal  peritonitis.  In  one 
case,  recently  observed  at  autopsy  in  the  Johns  Hopkins  Hospital  (Fig.  217), 
the  tip  of  the  appendix  was  distended  with  the  characteristic  yellow,  gelatinous 
exudate,  and  the  mucosa  of  this  pari  presented  extensive  areas  of  necrosis. 
The  proximal  half  was  hut  little  altered.  Histological  examination  of  the  dis- 
tended portion  showed  a  general  hyperemia  of  the  mucosa  and  a  considerable 
infiltration  of  round  cells.  A  few  polymorpho-nuclear  cells  were  seen  in  places. 
At  one  point  there  was  complete  necrosis  of  the  mucosa,  slightly  involving 
the  submucosa.  The  submucosa  was  infiltrated  with  abundant  round  cells 
and  a  tew  polymorpho-nuclear  leucocytes.  The  muscular  coats  were  only 
slightly  infiltrated,  hut  in  the  peritoneum  and  mesentery  the  infiltration  was 
marked.  Amoeba  are  found  in  the  exudate  at  the  margin  of  the  ulcer,  and  at 
one  point  in  a  distended  lymph  space.  A  second  case  presented  similar  lesions 
in  the  appendix,  chiefly  involving  the  proximal  half. 

BIBLIOGRAPHY. 

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AMOEBIC   DYSENTERY.  355 

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Kingdox:  New  Eng.  Quar.  Jour,  of  Med.,  1842-43. 

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356  PATHOLOGY. 

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CHAPTER  XVI. 
ETIOLOGY. 

PREDISPOSING    CAUSES.      EXCITING   CAUSES.      FINAL    CAUSES. 

The  various  factors  uniting  to  call  forth  an  attack  of  appendicitis  may  be 

considered    under    three     headings:      Predisposing,     exciting,    and 
f  i  11  a  1    or   essential. 

PREDISPOSING  CAUSES. 

Predisposing  causes  may  lie  local  or  general.  Among  the  most  important 
are  the  normal  anatomic  and  physiologic  conditions.  The  appendix  consists 
of  a  blind  sac  of  relatively  great  length  and  small  calibre,  possessing  a  narrow 
orifice;  it  resembles  the  tonsil  in  its  abundant  lymphoid  tissue,  and.  like  the 
latter,  borders  upon  a  cavity  particularly  rich  in  bacteria.  The  mechanical 
conditions  are,  therefore,  such  as  favor  the  stagnation  of  ingesta  and  an  in- 
crease in  the  virulence  of  the  contained  micro-organisms,  while  the  presence 
of  so  many  follicles  affords  a  convenient  portal  of  entry  for  bacteria.  It  is 
well  known  that  the  lymphoid  tissues  of  the  body  are  especially  prone  to  infec- 
tive processes,  and  the  researches  of  Stoiir  and  Uihbert  show  that  the  ade- 
noid tissue  of  mucous  membranes  is  easily  accessible  to  infections  from  the  sur- 
face. The  analogies  existing  between  the  appendix  and  the  tonsils,  pointed  out  in 
L876  by  Watney,  and  later  by  Sahli,  Soitherlaxd,  Ribbert.  Beck.  Adrian. 
and  others,  will  be  referred  to  further  in  considering  the  relation  of  appendi- 
citis to  general  infectious  diseases.  Morbid  anatomic  conditions,  resulting 
from  a  previous  acute  or  chronic  inflammation,  are  of  recognized  importance 
in  the  development  of  subsequent  attacks.  Riedel  believes  that  all  acute 
attack-  are  preceded  by  a  chronic  inflammation.  Roux  remarks  that  the 
processional  de  Vappendicite  finds  in  the  adenoid  tissue  and  in  the  residual  cica- 
trices, parietal  or  peri-appendical,  all  the  elements  necessary  to  contract  a  new 
appendicitis  on  the  occurrence  of  any  physiologic  hyperemia,  the  result  of  indi- 
gestion, or  of  cold,  or,  perhaps,  accompanying  menstruation.  These  conditions, 
as  well  as  their  influence  in  rendering  the  appendix  susceptible  to  recurrent 
attacks  of  inflammation,  have  been  fully  described  in  Chap.  XIII. 

A  similar  locus  minoris  resistentia  is  created  when  the  normal  appendix 
becomes  adherent  to  an  adjacent  structure,  a  frequent  complication  in  pelvic 
inflammation,  tumors,  etc.  I  am  acquainted  with  several  instances  in  which 
an  inflammatory  process  was  apparently  promoted  by  the  attachment  of  the 
appendix    to   the   site    of   a    previous    operation.     (See   Chap.    XXIX.)     The 

357 


3">S  ETIOLOGT. 

influence  of  the  Boating  right  kidney  as  an  etiologic  factor  in  the  develop- 
ment of  appendicitis  has  been  chiefly  upheld  by  Edebohls,  who  would  ascribe 
to  ii  an  important  rule  in  the  etiology  of  the  disease.  He  believes  thai  the 
kidney  acts  as  an  exciting  cause  indirectly  through  disturbance  of  the  circu- 
lation, owing  in  compression  of  the  superior  mesenteric  vessels  between  the  head 
hi  the  pancreas  and  t he  spines  ot'  the  vertebrie.  ('.  Beck,  on  the  other  hand, 
believes  thai  the  kidney  acts  as  a  direct  exciting  cause,  by  pressure  on  the  appen- 
dix itself.  W.  P.  Ma\to\  states  thai  in  his  experience  movable  kidney  is  the 
must  frequenl  cause  of  chronic  appendicitis.  Other  writers  have  observed  the 
occasional  coexistence  of  the  two  affections,  bul  do  nut  consider  that  the  relation 

of  cause  and  effect  is  always  clear.  ('.  P.  NOBLE,  in  10(1  operations  mi  cases 
of  movable  kidney,  did  not  observe  the  association  in  more  than  six.  Out 
of  lul  cases  of  movable  kidney  operated  upon  at  the  Johns  Hopkins  Hospital 
the  appendix  presented  evidence  of  chronic  inflammation  in  four. 

Age. — Appendicitis  is  distinctly  a  disease  of  early  life.  It  is  not  rare  in 
children  (see  Chap.  XX),  hut  is  most  common  between  ten  and  thirty  years  of 
age.  After  this  period  there  is  a  rapid  decrease  in  the  number  of  cases,  although 
it  is  by  no  means  rare  even  in  advanced  life.  Fit/,  described  a  case  in  a  man 
seventy-eight  years  of  age.  An  analysis  of  the  cases  of  acute  appendicitis  operated 
upon  at  the  Johns  Hopkins  Hospital  showed  that  78  per  cent,  were  under  thirty 
years,  aboul  an  equal  number  occurring  in  the  second  and  third  decades,  mid 
.">  per  cent,  in  the  first.  The  cases  operated  upon  for  chronic  appendicitis  for 
obvious  reasons  show  a  more  advanced  age.  Thus,  44  per  cent,  occurred  in  the 
third  decade  and  23  per  cent,  in  the  fourth,  while  only  Hi  per  cent,  were  under 
twenty  years.  The  well-recognized  susceptibility  of  lymphoid  tissues  to  infec- 
tions during  early  life  is  the  probable  explanation  of  the  prevalence  of  appendicitis 
at  this  period.  The  more  frequent  dietary  indiscretions  and  exposure  to  injury 
may  have  some  bearing  upon  this  point. 

Sex. — The  analysis  of  large  numbers  of  cases  demonstrates  the  greater  lia- 
bility of  the  male  sex  to  appendical  disease.  The  combined  statistics  of  several 
authors  give  a  percentage  of  75  in  males  and  25  in  females.  The  cases  of  the 
Munich  Hospital  reported  by  Einhorn  were  exceptional  in  presenting  a  larger 
percentage  in  women.  In  the  Surgical  Departmenl  of  the  Johns  Hopkins  Hos- 
pital the  percentage  in  acute  appendicitis  is  as  60  in  the  male  to  40  in  the  female. 
but  it  is  to  he  noticed  at  the  same  time  that  a  number  of  eases  were 
observed  in  the  gynecological  service  (see  Chap.  XXIX).  The  striking  differ- 
ence in  the  two  sexes  is  often  erroneously  explained  by  the  supposed 
difference  in  the  vascular  supply  of  the  organ,  based  on  the  mistaken 
view  that  in  the  female  it  receives  a  special  branch  from  the  ovarian  artery.  A 
really  plausible  explanation  is  found  in  the  greater  liability  to  exposure  to 
injury  and  the  greater  tendency  to  errors  in  diet  in  the  male  sex.  The  ex- 
cessive  use  of  tobacco  and  the  consequent  digestive  disturbances  may  also 
account    for   some   cases.      Byrox   Robixsox    advances    the  theorv  that   the 


PREDISPOSING    CAUSES.  359 

relation  of  the  appendix  to  the  psoas  muscle  may  explain  the  greater  fre- 
quency of  appendicitis  in  males.  The  psoas  in  them  is  longer,  broader,  and 
more  developed  generally,  thus  offering  a  greater  surface  for  contact  with  the 
appendix.  This  disparity  is  further  increased  by  the  shape  of  the  pelvis, 
which  is  long  and  narrow. 

Nationality. — This  is  apparently  an  insignificant  factor  in  the  development 
of  the  disease.  The  great  increase  in  the  number  of  cases  reported  during  the 
past  few  years  is  universal,  and  wherever  the  disease  is  carefully  observed  it  is 
recognized  as  of  common  occurrence.  The  negro  race,  however,  seems  to  be 
comparatively  exempt  from  the  affection.  In  order  to  obtain  some  information 
upon  this  point  I  wrote  to  several  surgeons  practising  in  southern  cities 
having  a  large  proportion  of  negro  inhabitants.  The  replies  were  unanimous  in 
regard  to  the  rarity  of  the  disease  in  this  race.  S.  C.  Bkiggs,  of  Nashville,  Tenn., 
out  of  several  hundred  operations  for  appendicitis  could  recall  only  one  upon  a 
negro.  He  stated,  however,  that  as  the  colored  race  in  the  South  have  their 
own  physicians,  they  did  not  always  come  under  the  observation  of  others; 
nevertheless  he  thought  that  the  disease  was  rare.  H.  J.  Inge,  of  Mobile.  Ala., 
out  of  149  operations  had  but  one  in  a  negro,  and  by  inquiry  among  other 
physicians  found  its  occurrence  in  the  race  to  be  equally  rare  in  their  experience. 
G.  B.  Noble,  of  Atlanta,  Ga.,  had  never  operated  upon  a  negro  for  appendicitis. 
L.  L.  Hill,  of  Montgomery,  Ala.  (in  the  "black  belt  "),  with  a  colored  popu- 
lation of  9000,  could  collect  the  histories  of  only  four  cases  that  had  oc- 
curred among  them,  and  found  that  the  physician  who  had  been  consultant 
for  a  number  of  years  at  Hooker  Washington's  school,  where  there  are  about 
fourteen  hundred  colored  students,  did  not  remember  ever  to  have  seen  a 
case  there;  at  the  Alabama  Polytechnic  Institute,  however,  twenty  miles 
distant,  where  there  are  400  boys,  there  was  an  annual  average  of  eight  ca-e~. 
At  the  former  school  the  diet  is  simple  and  the  same  for  all,  but  at  the 
latter  the  cadets  live  at  different  boarding-houses  in  the  town.  There  are  S00 
negro  prisoners  at  one  of  the  Alabama  coal-mines  and  the  physician  in  charge 
states  that  appendicitis  is  unknown  among  them.  The  explanation  given  for  this 
relative  exemption  of  the  negro  is  that  their  diet  is  simple,  they  take  a  great  deal 
of  outdoor  exercise,  and  they  are  free  from  digestive  disturbances.  The  stat- 
istics of  the  Johns  Hopkins  Hospital  show  that  while  the  number  of  admissions  of 
colored  to  white  averages  about  1  to  4,  the  number  of  cases  operated  upon  for 
appendicitis  is  as  1  to  12. 

Hereditary  Influence. — Lennander  (Beit.  z.  klin.  Med.  u.  Chir.,  1895) 
characterizes  appendicitis  as  a  family  disease,  ami  most  physicians  of 
wide  experience  are  impressed  with  the  remarkable  frequency  of  its  oc- 
currence in  members  of  the  same  family.  Brothers  and  sisters  are 
affected  more  often  than  parent  and  child,  although  the  latter  associa- 
tion is  not  uncommon.  A.  McCosh  (Amer.  Jour.  Med.  Set.,  May,  1897)  reports 
three  cases  in  three  successive  generations,  and  Finney  (personal  communi- 


3t')()  ETIOLOGY. 

cation)  had  five  cases  in  one  family,  the  father,  two  sons,  and  two  daughters 
being  affected.  In  one  of  the  Johns  Hopkins  Hospital  cases  a  girl,  twelve  years 
of  age,  was  operated  on  for  acute  appendicitis  while  her  father  was  still  in  the 
ward  convalescing  after  operation,  also  performed  during  an  acute  attack.  In 
several  cases  there  was  a  history  of  one  or  more  brothers  and  sisters  similarly 
affected;  in  one  instance  two  brothers  of  the  patient  had  been  operated  upon 
for  appendicitis  in  the  Johns  Hopkins  Hospital — one  four,  the  other  two  years 
previously.  A  family  predisposition  is  explicable  upon  the  ground  of  anatomic 
peculiarities  and  constitutional  predisposition.  It  is  well  known  that  in  some 
families  there  is  a  marked  tendency  toward  affections  of  the  lymphoid  tissues. 
As  a  rule,  I  he  ailed  ion  appears  in  the  various  members  of  the  family  at  differ- 
ent periods,  but  there  are  a  considerable  number  of  observations  referring  to  its 
development  in  two  or  more  at  the  same  time.  F.  W.  Sears,  of  Albany,  has 
furnished  me  with  the  following  cases : 

1.  Boy,  thirteen  years  old,  operated  on  the  morning  after  the  onset  of  the 
second  acute  attack.  The  appendix,  which  was  surrounded  by  omentum,  was 
perforated  and  there  was  considerable  j >uss  present. 

2.  four  days  later  his  sister,  nine  years  old,  who  had  always  been  well,  was 
seized  with  a  sharp  attack  of  appendicitis  and  was  operated  on  three  days  later. 
In  this  case  the  omentum  had  formed  a  pocket  in  which  the  perforated  tip  of  the 
appendix  was  buried. 

3.  The  daughter  of  a  physician,  age  nineteen.  Second  attack  of  acute  ap- 
pendicitis. Operation  the  following  morning.  The  appendix  was  perforated  close 
to  the  cecum  and  there  was  beginning  peritonitis. 

4.  Eight  days  later  her  sister,  twenty-one  years  old,  who  had  been  well, 
was  taken  with  an  acute  attack  and  was  operated  on  the  next  morning.  The  ap- 
pendix was  perforated, but  the  peritoneum  was  protected  by  the  adherent  omentum. 

These  instances  of  coincident  attacks  in  members  of  the  same  family  sug- 
gest the  presence  of  a  general  infectious  origin,  and  will  be  referred  to  later  in 
that  connection. 

EXCITING  CAUSES. 
Disorders  of  Digestion.— These  have  the  most  important  influence  in  deter- 
miningan  acute  attack  of  appendicitis.  In  many  cases  there  is  a  history  of  chronic 
constipation  and  indigestion.  Sometimes  an  acute  attack  comes  on  shortly  aftera 
hearty  meal  of  unsuitable  food.  Less  frequently,  diarrhea,  sometimes  associated 
with  symptoms  of  acute  entero-colitis,  precedes  the  onset  of  the  appendical 
trouble.  In  the  cases  at  the. Johns  Hopkins  Hospital  there  was  a  history  of  con- 
stipation immediately  preceding  the  attack  in  43  per  cent.  In  50  per  cent,  the 
bowels  were  regular,  but  in  many  of  these  cases  there  was  a  history  of  indigestion, 
ami  it  must  always  be  remembered  that  the  patient's  statement  that  the  bowels 
were  regular  is  not  a  proof  that  there  was  no  constipation.  For  example,  in  a 
recent  case  of  J.  C.  Bloodoood's  the  patient  asserted  that  her  bowels  were  regu- 


EXCITING    CAUSES.  361 

lar,  but  at  operation  the  colon  was  found  tilled  with  scybalous  masses,  which  were 
also  present  in  the  cecum.  In  several  instances  the  onset  of  the  at  lack  was  marked 
by  more  or  less  severe  diarrhea,  but  this  symptom  was  rarely  present  earlier  and 
was  frequently  preceded  by  constipation.  Frequently,  as  mentioned  above,  the 
attack  may  be  directly  traced  to  an  undigestible  meal.  This  was  true  in  a  consid- 
erable number  of  cases;  in  some  of  which  the  attack  immediately  followed  the 
ingestion  of  unsuitable  food,  hut  usually  occurred  some  hours  afterward.  A  com- 
mon history  in  the  account  of  events  immediately  preceding  the  attack,  is  that 
the  patient  had  partaken  of  an  unusually  hearty  supper  and  a  few  hours  later 
was  awakened  from  sound  sleep  by  agonizing  colicky  pain  in  the  abdomen, 
accompanied  by  vomiting. 

Menstruation. — The  intimate  relation  existing  between  the  menstrual 
periods  and  appendicitis  has  been  frequently  noted,  not  only  when  the  appendix 
is  situated  in  the  pelvis,  but  when  it  is  retrocecal.  The  probable  explanation 
lies  in  the  fact  that  the  congestion  of  the  whole  splanchnic  area  which  accom- 
panies the  lowered  blood-pressure  of  the  peripheral  circulation  during  menstru- 
ation creates  a  favorable  soil  for  the  activities  of  the  micro-organisms  contained 
in  the  appendix.  I  have  observed  this  association  in  several  instances,  in  some  of 
which  the  recurrent  appendical  attacks  invariably  occurred  at  the  menstrual 
period.     A  good  example  is  in  the  following  case: 

A  girl,  age  eighteen,  was  admitted  to  the  Gynecological  Department  of  the  Johns 
Hopkins  Hospital  with  a  history  of  five  attacks  of  acute  appendicitis  associated  with 
menstrual  periods,  the  last  three  attacks  occurring  in  consecutive  months.  While 
under  observation  in  the  ward  at  the  beginning  of  menstruation,  she  was  seized  with 
pain  in  the  right  side  a  little  above  McBumey's  point  and  extending  to  the  lumbar 
region.  There  was  marked  tenderness  and  indefinite  resistance  in  this  area.  The 
temperature  was  normal  and  there  was  no  leucocytosis.  The  pain  and  tenderness 
steadily  increased,  and  the  next  morning  the  temperature  was  100°  F..  the  leucocy- 
tosis 7,000;  in  the  afternoon  there  was  well-marked  resistance  in  the  right  lumbar 
region,  and  the  temperature  was  100.8°  F.,  the  leucocytosis  16.000.  At  operation 
the  appendix  was  found  acutely  inflamed,  greatly  swollen,  and  embedded  in  a  mass 
of  inflammatory  exudate. 

Trauma. — Trauma  is  a  direct  factor  in  the  causation  of  some  cases  of  appen- 
dicitis, more  often  than  has  been  supposed.  Indirect  injury,  such  as  straining 
in  heavy  lifting,  is  a  more  common  catise  than  a  direct  Mow.  In  one  of  our  cases 
the  attack  followed  immediately  upon  a  long,  hard  bicycle  ride;  in  another 
the  patient  jumped  from  a  street-car  and  was  immediately  seized  with  abdominal 
pain  so  severe  that  he  could  not  straighten  up.  In  another,  again,  the  patient 
had  been  in  swimming  for  an  hour  when  he  was  seized  with  a  sharp,  knife-like 
pain  in  the  right  side,  which  he  attributed  to  cramp.  The  etiologic  influence 
of  injury  has  been  considered  in  detail  in  discussing  the  medico-legal  aspects 
ot  appendicitis.     (See  Chap.  XXXIII.) 

Exposure  to  cold  occasionally  bears  a  direct  relation  to  the  development  of  an 


3(i2 


ETIOLOG1 . 


attack  of  appendicitis.  It  resembles  in  its  actios  the  physiologic  congestions 
due  to  other  causes,  and  is  most  liable  to  induce  an  acute  attack  in  an  appendix 
predisposed  to  inflammatory  disease  as  the  result  of  a  previous  attack. 

Foreign  Bodies  and  Concretions.  A  few  years  ago  the  origin  of  appen- 
dicitis was  frequently  attributed  to  the  influence  of  foreign  bodies,  the  seeds  of 
various  fruits  being  mosi  frequently  described.  Now,  however,  it  is  generally 
recognized  that  in  the  majority  of  cases  appendicitis  is  not  associated  with 
the  presence  of  foreign  bodies  or  concretions;  that  true  foreign  bodies  are  com- 
paratively rare;  and  that  concretions,  although  present  in  a  considerable  number 
of  cases,  probably  play  a  subsidiary  role  in  the  production  of  the  disease.  The 
frequency  of  foreign  bodies  in  the  appendix  is  indicated  by  the  statistics  of 


Fig,  218. — Subacute  Appendicitis  Associated  with  the  Presence  op  Two  Coni  ri  noNS. 
The  prominences  a  and  l>  mark  the  site  of  the  concretions  (a'  ami  b').     The  former  bod}   beat     i    triking 
re  i  mblance   '"    >  hazelnut,  while  a  genuine  fragment  of  nut-shell  i    embedded  in  the  latter.     (Specimen  from 
r  he  I  rerman  II"  pital,  Philadelphia.) 


various  recent  observers.  Thus,  A.  0.  J.  Kelly,  examining  4li()  specimens, 
only  once  found  a  foreign  bod}-,  which  was  a  pin;  Hawkins  found  none  in  07 
fatal   cases;     BELL,   ill   about    1000  cases   found   five  foreign   bodies,   a   lish-bone, 

a  core  of  apple,  two  pins,  and  a  lumbricus;  Murphy  found  foreign  bodies  in 
3.5  percent.;  while  Friz,  writing  in  1886,  noticed  their  presence  in  1l'  per  cent, 
of  the  perforative  cases,  ami  Matterstock,  in  1880,  also  found  them 
in  12  per  cent,  of  his  cases.  In  almost  1000  cases  of  appeni  licit  is  in  the  Johns 
Hopkins  Hospital  foreign  bodies  have  been  found  in  four  cases,  a  segment  of 
tape-worm,  a  mass  of  oxyurides  in  two.  and  a  pin.  Many  of  the  seeds  described 
in  the  older  literature  were  undoubtedly  merely  fecal  concretions,  which  frequently 
assume  the  appearance  of  a  cherry  or  date  stone  and  sometimes  are  recognized 
only  by  the  most  careful  examination.     The  case  shown  in  Fig.  21S  is  a  good 


EXCITIXG    CAUSES. 


363 


example  of  the  simulation  of  a  foreign  body  by  a  concretion.  In  size  and  shape  the 
mass  exactly  corresponds  to  a  hazelnut,  and  indeed  the  drawing  was  made  under 
the  impression  that  it  was  such.  The  presence  of  a  fragment  of  nut-shell  in  the  sec- 
ond concretion,  together  with  the  fact  that  the  appendix  was  of  the  fetal  type  and 
would  readily  permit  the  entrance  of  a  comparatively  large  body,  seemed  to  con- 
firm this  view,  but  the  detection  of  extraneous  material  in  the  interim-  of  the 
mass  and  its  general  structure  showed  that  it  was  merely  a  concretion.  Gall- 
stones, also,  which  formerly  were  <upposed  to  enter  the  appendix  frequently, 
are  exceedingly  rare;  but  they  are  often  so  closely  simu- 
lated by  enteroliths  that  a  chemical  analysis  is  necessary 
for  their  exclusion.  The  clinical  evidence  in  some  of 
these  cases  so  strongly  supports  the  gall-stone  theory  as 
to  leave  no  doubt  in  the  mind  of  the  observer.  A  case 
in  point,  observed  in  the  Surgical  Department  of  the 
Johns  Hopkins  Hospital,  is  as  follows : 


Fig.  219.  —  Appendix 
Containing  Entero- 
liths Resembling 
<  iAX.Lr8  roNEa  Spec- 
imen  from  Rogei-.) 


L.  F.,  age  twenty-four.  Admitted  with  a  typical  history 
of  stone  in  the  gall-bladder  and  in  the  common  duct,  and  of 
their  appearance  in  the  stools.  At  operation  about  100  small 
facetted  calculi  were  removed  from  the  gall-bladder.  The 
patient  was  discharged  well.  About  fourteen  months  later 
she  returned  complaining  of  sticking  pain  in  the  region  of  the 
gall-bladder,  which,  however,  was  unlike  the  former  attacks 
in  character.  This  had  been  of  a  few  clays'  duration  and  was 
accompanied  with  vomiting.  Operation  revealed  a  few  ad- 
hesions about  the  gall-bladder  ami  the  omentum  closely 
adherent  to  the  chronically  inflamed  appendix.  The  removed 
appendix  (Fig.  3.  Plate  III)  presented  a  stricture  1  cm.  from 
the  tip,  and  contained  soft,  tenacious  fecal  material  which 

formed  a  mould  of  the  whole  lumen.  Within  it  there  were  three  hard,  irregular 
bodies;  the  largest  one,  in  the  centre,  was  a  cube  about  1  cm.  in  diameter 
with  facetted,  slightly  hollowed  surfaces.  It  was  dark  brown  in  color,  excepl 
for  a  superficial  layer  of  white,  corresponding  to  the  appearance  of  the  calculi 
removed  from  the  gall-bladder  at  the  first  operation.  The  diagnosis  was  chronic 
appendicitis  due  to  the  presence  of  gall-stones.  An  analysis  of  the  facetted  stone 
made  by  L.  Mendel,  of  Harvard,  showed  that  it  was  a  typical  enterolith.  The 
nucleus  was  a  small  particle  resembling  a  raspberry  seed:  the  remainder  consisted 
chiefly  of  calcium  phosphate  with  some  magnesium  sulphate,  traces  of  carbonate. 
some  fat,  and  amorphous  material. 


A  similar  history  was  given  by  the  patient  from  whom  the  appendix  shown  in 
Fig.  219  was  removed,  and  the  operator,  Dr.  Rogers,  naturally  made  a  diagnosis 
of  gall-stones  in  the  appendix.  In  Fig.  220  an  appendix  is  shown  which  appar- 
ently contains  a  genuine  gall-stone.     The  specimen  furnished  by  James  Bell, 


364 


KTIOI.OCV. 


I  220.      Aii  i  m.i\  Coni  UNINO  a  Cal- 
culi's, Probably   \  Gall-stone. 


of  Montreal,  was  removed  from  a  young  woman,  twenty-two  years  old,  on  the 

second  <  lay  of  an  acute  attack.  There  was  a 
history  of  an  attack  of  appendicitis  of  nine 
years  before.  The  diagnosis  of  gall-stones  was 
made  from  the  appearance  of  the  body  and  from 
its  composition,  which  consisted  largely  of 
cholesterin.  In  tins  case,  also,  the  appendix 
had  a  wide  orifice.  In  a  similar  case,  furnished 
by  ( i.  W.  &ULE,  of  Cleveland,  (  >hio,  the  acutely 
inflamed  appendix,  which  was  short  and  funnel- 
shaped,  contained  a  good-sized  calculus,  which 
chemical  analysis  showed  to  be  a  true  gall- 
stone. 

While,  however,  many  observations,  owing 

to  lack  of  careful  examination,  are  unreliable, 
in  some  instances  foreign  bodies  undoubtedly 
gain  access  to  the  appendix  and  directly  pro- 
voke the  inflammatory  process.  Among  the 
objects  that  have  been  found  in  the  appendix 
are  pins,  shot,  pieces  of  lead,  bones, hairs,  bris- 
tles,  various  seeds,  and  enterozoa.  The  cases 
in  the  literature  with  especial  reference  to  the 
occurrence  of  pins  in  the  appendix  have  been  carefully  investigated  by  J.  F. 
Mitchell  (Johns  Hopkins  Hospital  Bull.,  1894,  p.  35), 
who  arrives  at  the  following  conclusions:  "  foreign  bodies 
are  now  known  to  play  a  much  smaller  role  in  appendicitis 
than  that  formerly  accredited  to  them.  The  appendix 
would  seem  to  act  especially  as  a  trap  for  pointed  bodies 
and  for  small  heavy  objects  like  shot  or  bullets.  Con- 
spicuous among  pointed  bodies  are  pins,  which  are  the 
commonest  and  at  the  same  time  the  most  dangerous  of  all 
foreign  bodies."  Bodies  of  light  weight,  like  the  classical 
grape-seeds  and  cherry-stones,  are  exceptional.  The  ex- 
planation of  this  fact  is  that  on  account  of  their  shape  and 
weight,  pointed  and  heavy  bodies  more  readily  become 
engaged  in  the  appendical  orifice  and  pass  into  the  canal. 
It  is  a  curious  fact  that  pins  rarely  perforate  the  cecum  or 
small  intestine.  It  is  almost  impossible  for  the  seeds  of 
cherries,  dates,  oranges,  etc.,  to  enter  the  lumen  of  the 
appendix,  except  in  cases  where  the  fetal  type  is  pre- 
served.  Small  seeds,  such  as  those  of  berries,  are  not  in- 
frequent, and  I  have  repeatedly  demonstrated  their  presence  under  the 
microscope    (see   Fig.   221),    but    they   are   of   no   special    significance   in   the 


Fio.    22]        Appendix 

< '  ii  \   I    II  NINO    TWO 

S  M  A  M.     S  E  V.  !>  s     AT 

Points    1  NDXCATED 
by  a. 


EXCITING   CAUSES.  365 

etiology  of  appendicitis,  as  they  merely  form  part  of  the  fecal  material 
commonly  found  in  the  appendix.  The  following  cases  of  foreign  bodies 
in  the  appendix,  collected  from  the  literature  and  from  personal  communi- 
cations, bring  out  some  interesting  facts  regarding  the  frequency  of  certain 
kinds  of  bodies  and  their  pathogenicity.  My  list  includes  all  the  cases  cited 
by  Mitchell  in  his  article,  and  a  number  of  additional  cases  as  well.  I  have 
not  included  cases  in  which  the  right  iliac  abscess  containing  the  foreign  body 
was  not  demonstrated  to  be  of  appendiceal  origin. 

1.  Mestivier.  Jour,  de  vied.  chir.  et  pharm.,  etc.,  1759,  torn.  10,  p.  441.  Man, 
age  forty-five.  Abscess.  Incision.  Autopsy:  In  the  appendix,  a  large  pin 
encrusted  and  eroded  so  that  the  least  force  would  break  it.  No  history  of  having 
swallowed  it. 

2.  Kingdon.  N.  E.  Quart.  Jour,  of  Med.,  1842-43,  vol.  1.  Boy,  age  seven. 
Difficulty  in  micturition  and  repeated  passage  of  worms  from  the  urethra;  passage 
of  urine  from  anus.  Death  at  end  of  three  years  from  exhaustion.  Autopsy  :  Showed 
the  appendix  adherent  to,  and  opening  into  the  upper  part  of  the  bladder,  which 
contained  a  calculus  formed  around  a  large  pin,  that  had  obviously  escaped  from 
the  appendix.     No  history  of  having  swallowed  pin. 

3.  Bboca.  Bull,  de  la  Soc.  anat.,  1849,  torn.  24,  p.  3G4.  Child  dead  of  pulmonary 
tuberculosis  and  an  enormous  abscess  of  the  liver.  No  symptoms  connected  with 
the  appendix  during  life.  The  pin  had  perforated  the  adherent  portion  of  the  ap- 
pendix.    There  were  no  signs  of  peritonitis. 

4.  Parrot.  Bull.  Soc.  anat.  de  Paris,  1855,  torn.  54.  Man,  age  twenty-four. 
Right  iliac  tumor  for  twelve  years.  Spontaneous  rupture  and  fecal  fistula.  Probe 
encountered  a  hard  body  which  was  removed  and  found  to  be  an  ordinary  pin,  with 
point  free,  but  otherwise  encrusted  with  hard  fecal  matter.  Death  of  general  peri- 
tonitis. Patient  did  not  remember  swallowing  pin.  Autopsy:  Showed  a 
fistula  leading  into  a  cavity  into  which  the  vermiform  appendix  opened. 

5.  Joffroy.  Bull.  Soc.  anat.  de  Paris,  1869,  torn.  44,  p.  512.  Girl,  age  ten. 
Symptoms  suggested  typhoid  peritonitis.  Acute  appendicitis.  Death  in  two 
months.  A  u  t  o  p  s  y :  Circumscribed  abscess  in  right  iliac  fossa.  In  the  appendix  a 
pin  of  large  size  which  had  entered  head  first  and  penetrated  the  appendix  wall  with 
its  point.     Pin  surrounded  with  fecal  matter. 

6.  Payne.  Trans.  Path.  Sac.  London,  1S70.  vol.  31,  231.  Woman,  age  thirty- 
seven.  Illness  of  three  weeks.  Headache,  abdominal  pain  and  tenderness;  tem- 
perature 104°  V.,  delirium,  death.  Autops  y :  In  the  appendix  was  a  medium-sized 
black  pin,  the  head  and  three-quarters  of  the  shaft  surrounded  by  a  fecal  concretion. 
The  bare  point  of  pin  projected  into  the  cecum.  Appendix  wall  thickened,  but  no 
signs  of  acute  inflammation.  No  general  peritonitis.  Abscesses  of  liver  and 
lungs. 

7.  Lego.  St.  Barth.  Hospital  Reports,  London,  1875.  vol.  11,  p.  85.  Girl,  age  six. 
Following  scarlet  fever,  abscess  in  the  groin  appeared,  which  opened  spontane- 
ously. Patient  well  for  a  time,  then  began  to  waste  away.  Abscess  developed 
m  epigastrium,  was  opened,  discharged  a  great  deal  of  pus,  and  healed.  Twelve 
days   later,   abdominal   distention,    vomiting,    death.      Autopsy:    Multiple    ab- 


366  ETIOLOGY. 

scesses  among  intestines.     The  appendix  was  perforated  close  in  the  cecum  and  con- 
tained a  large  pin,  rusty  on  its  head  and  upper  third. 

8.  Whipham.  Trans.  Clin.  Sue.  London,  1879,  vol.  12, p.  58.  Boy,  age  eighteen. 
Illness  began  five  months  before;  acute  recurrence  seven  days  before  death.  A  u  - 
topsy:  Localized  abscess  in  right  iliac  fossa;  purulent  and  fecal  contents; 
a  pin  U  inches  long  found  free  in  abscess.  The  appendix,  doubled  on  itself ,  was 
perforated  on  both  sides  of  the  fold.  Appendix  adherent  to  cecum,  with  perforation 
into  it. 

9.  Asiir.v.  Lancet,  London,  1879,  vol.  2,  p.  649.  Girl,  age  eight.  Four  months' 
illness;  appendicitis.  Autopsy:  Appendix  contained  a  pin  encrusted  with 
phosphates  and  with  its  point  sticking  through  appendix  wall.  Near  this  spot  was 
a  ragged  ulcer  adherent  to  surrounding  parts.  Large  abscess  of  liver.  No  history 
of  swallowing  pin. 

Hi.  Harley.  Diseases  of  th<  L/iver,  London,  1883,  p.  846.  Boy,  age  nineteen. 
Fever,  rapid  pulse,  tenderness  over  the  liver.  Death  in  nine  days.  Au- 
topsy: Large  abscess  of  the  liver.  At  the  apex  of  the  appendix  a  thick 
brass  pin  1 ',  inches  long,  head  somewhat  green  and  eroded,  pointing  downward,  and 
projecting  through   the  caudal  extremity  of  the  appendix. 

11.  McBirxkv,  New  York,  INNS.  (Pirmtml  communication.)  Boy,  age  ten. 
Pvight  inguinal  hernia  contained  the  inflamed,  thickened  appendix,  the  bulbous  distal 
end  aliout  1  inch  across.  In  this  mass,  the  points  piercing  one  side  and  the  heads 
the  other,  were  two  black  pins,  lying  close  together.  The  vermiform  appendix 
amputated  and  case  finished  as  one  of  hernia.     Recovery. 

12.  Baker.  Brit.  Med.  Jour.,  1889,  p.  1347.  Man.  Swelling  in  right  iliac  fossa 
and  symptoms  of  intestinal  obstruction.  Median  incision;  evacuation  of  fetid  pus. 
Death  six  weeks  later.  Autopsy:  Pin.  with  point  protruding  through 
the  appendix  ami  head  buried  in  a  mass  of  fecal  matter. 

13.  Shoemaker.  Trans.  Coll.  Phys.,  Philadelphia,  1892-93,  vol.  14.  p.  214, 
Man.  age  eighteen.  Illness  of  twelve  days.  Acme  appendicitis,  general  peritonitis, 
operation,  death.  Autopsy:  General  peritonitis,  ruptured  liver  abscess. 
Appendix  not  ruptured  but  gangrenous  and  containing  a  common  pin,  head  down- 
ward. 

II.  Bell.  Canada  Med.  Rec.,  Nov.,  1894.  Boy,  age  six.  Acute  appendicitis, 
following  blow  on  abdomen  two  days  before.  Operation:  on  opening  the  ap- 
pendix a  pin  was  found  lying  transversely  in  its  lumen  near  the  tip.  The  head  had 
ulcerated  through  the  wall  of  the  appendix  and  the  point  had  nearly  perforated  the 
opposite  side  at  this  point,  which  was  strengthened  by  adherent  omentum.  Re- 
covery. 

15.  Willard  and  Lloyd.  Trims.  I'ntli.  Sue.  Philadelphia,  1894,  vol.  17,  p.  40. 
P>oy.  age  nine.  Acute  appendicitis  forsixdays.  Operation:  incision  and  drainage 
of  abscess;  death.  Autopsy:  general  peritonitis,  multiple  abscess  of  liver. 
The  appendix  contained  a  large  pin  with  its  head  downward  and  its  point  projecting 
through  a  perforation  near  its  base. 

Hi.  Park.  A.  }".  Med.  Rec,  IN'.).-),  vol.  47.  p.  345.  Man.  age  thirty-two. 
Indefinite  discomfort  in  right  iliac  fossa  for  five  years.  Acute  attack  for  one  week. 
Operation:    removal     of    appendix,     drainage    of     abscess.      The    appendix 


EXCITIXG   CAUSES.  367 

contained  a  concretion  §  of  an  inch  long,  and  having  the  diameter  of  a  lead-pencil. 
Embedded  in  it  was  a  common  pin  with  the  point  protruding.  No  knowledge  of 
having  swallowed  the  pin.     Recovery. 

17.  McPhedren  and  Caven.  Canada  Pract,  1895.  vol.  20,  p.  180.  Man, 
age  twenty-one.  Illness  of  about  six  months.  Pyemic  symptoms.  Au- 
topsy: multiple  liver  abscesses,  one  connecting  with  abscess  in  right  pleural  cavity 
which  communicated  with  bronchi.  Appendix  thickened  and  dilated,  contracted  in 
its  middle,  and  in  dilated  cavity  beyond  containing  a  large  common  pin,  bent  at 
an  obtuse  angle  and  with  its  tip  embedded  for  \  of  an  inch  in  the  appendix 
wall.     Pin  largely  covered  with  calcareous  matter,  laid  down  in  a  regular  coat. 

18.  Colmek.  Lancet,  London,  1895,  vol.  1,  p.  745.  Boy,  age  seven  and  one-half 
years.  Three  days  illness.  Constipation,  vomiting,  abdominal  pain.  Sudden  death. 
Autopsy:  recent  general  peritonitis:  the  appendix,  thickened,  enlarged,  and  per- 
forated, contained  a  fecal  concretion  resembling  a  date-stone,  and  enclosing  a  pin, 
whose  point  projected  through  the  perforation. 

19.  Abbe,  New  York,  1895.  (Personal  communication.)  Child,  aire  five.  Oper- 
ation: the  appendix  had  been  perforated  by  a  pin  which  had  ulcerated  out  and 
was  in  an  abscess  cavity  of  which  the  sloughing  appendix  was  the  centre.  The  pin 
was  considerably  encrusted  with  salts.  No  history  of  the  pin  having  been 
swallowed. 

20.  Kammerer.  Ann.  Surg.,  1*95,  vol.  22,  p.  274.  Boy,  age  seven.  Illness 
of  a  week.  Tumor.  Operation:  tumor  in  the  omentum  in  which  the  distal 
half  of  the  appendix  was  firmly  embedded.  A  common  pin  had  passed  through  the 
appendix  and  escaped  through  a  perforation  in  the  tip.  The  firm  adhesions  of 
the  appendix  to  the  omentum  showed  that  this  could  not  have  been  the  first  attack. 

21.  McBtjrney,  New  York.  1896.  (Personal communication.)  Man,  age  twenty- 
nine.  Illness  of  five  days,  pain  and  tenderness  in  right  iliac  fossa.  Operation: 
incision  made  over  tumor  under  ether.  H  ounces  of  pus  evacuated.  In  the 
abscess  cavity  was  a  large,  soft  concretion  with  an  ordinary  pin  as  nucleus.  The 
appendix  had  sloughed  off  near  its  base.     Recover}'. 

22.  Syms.  Ann.  Surg.,  1896,  vol.  23,  p.  624.  Woman,  age  twenty-one. 
Seven  years  before,  appendicitis  with  large  abscess  which  opened  spontaneously  and 
healed.  Repeated  similar  abscesses  for  six  years.  Finally,  a  large  abscess  was  opened 
and  drained.  Second  operation,  for  persisting  sinus,  showed  the  tip  of  the  appendix 
attached  to  fascia  under  which  was  a  cavity  to  which  the  sinus  led.  The  appendix 
contained  a  pin,  the  head  of  which  was  the  nucleus  of  a  hard,  fecal  concretion. 

23.  Roberts.  Amer.  Pract.  and 'News,  Louisville,  1896.  vol.  21,  p.  491.  Boy,  age 
fifteen  months.  Illness  of  one  day.  Strangulated  right  inguinal  hernia.  Opera- 
tion: contents  of  hernia  found  to  lie  the  cecum  and  appendix.  A  pin  was  in 
the  appendix  with  point  protruding  through  the  posterior  wall  and  into  the  dartos 
of  the  scrotum.     Appendix  removed  and  cecum  returned.      Recovery. 

24.  Deavek.  Treatise  on  Appendicitis,  1896,  p.  'AG.  Woman,age  thirty-three. 
Acute  appendicitis  for  one  week.  Operation:  appendix  removed.  Omentum 
adherent,  no  pus.     Appendix  contained  a  black  pin  which  had  entered  point  first. 

25.  Moriata.  X.  Y.  Med.  Jour.,  1S96,  vol.  54.  p.  547.  Boy.  age  fourteen. 
Acute   appendicitis    following  a  kick.       Operation:     Appendix    found    to    be 


368 


i:i-|<>i.oi;y. 


swollen  and  perforated.  An  ordinary  pin  was  found  in  the  appendix,  with  its  head 
pointing  downward  and  its  point  caught  in  the  side  of  the  organ.  Death  three 
weeks  later.     Boy  asserted  thai  he  had  swallowed  pin  a  \ear  previously. 

26.  Daland.  Proc.  Path.  Soc.  Phila.,  1897.  Man.  adult.  For  some  months 
pain  in  region  of  appendix.  Acute  appendicitis  for  ten  days.  Operation: 
appendix  removed  and  abscess  evacuated.  Appendix  found  to  contain  an  ordi- 
nary pin :  no  perforation,  but  evidence  of  chronic  inflammation  shown  by  thickened 
walls  and  adhesions.     No  history  of  having  swallowed  the  pin. 

'_'7.  Lee.  Limed.  London,  1897,  vol.  2,  p.  536.  Woman,  age  not  given.  Sud- 
den   seizure    with    violent    pain    in    the    abdomen.      Death    soon    after.     Ati- 


App' 


Ilto    cecal 
valvt 


Fig.  222. — Appendix  Pf.rfohatf.h  by  a  Fin.     (Specimen  from  H.   D.  Roltpston.     Case  30.) 


topsy:    appendix    contained     a     pin,   the     point     of    which     had     caused    a    per- 
foration at  the  tip.  communicating  with  an  abscess  in  the  peritoneal  cavity. 

28.  Ochsner,  Chicago,  1897.  {Personal  communication.)  Woman,  age  twenty- 
three.  For  nine  years  attacks  of  pain  in  right  iliac  region,  associated  with  tumor 
formation  two  years  In-fore.  Abscess  incised  and  drained.  Persistence  of  fecal  fis- 
tula. Opera  t  ion:  incision  of  the  fistula.  A  pin  discovered  with  its  larger 
end  covered  by  a  concretion  2.5  X  1.5  cm.  in  size.  Later  operation:  incision 
through  bonier  of  right  rectus  exposing  the  cecum  and  the  appendix  which  opened 
directly  into  the  fistula. 

29.  Officer.  Intercol.  Med.  Jour,  of  Australia,  1898,  p.  229.  Boy  age  six. 
Ill  nine  days,  then  si<rns  of  general  peritonitis.  Operation:  peritoneal 
cavity     full     of     pus.      Irrigation,     drainage.      Death     in     thirty     hours.     A  tt  - 


EXCITING    CAUSES. 


369 


top  By:    appendix    contained    an    ordinary    pin    which    had    ulcerated    through 
the  wall  and  was  lying  partly  across  the  lumen. 

30.  Rolleston.  Trans.  Path.  Soc.  London,  vol.  49.  Girl,  age  seven.  Stitch 
in  right  side  for  a  year  or  two.  Five  weeks  before  death  signs  of  right-sided 
pleurisy.  Later,  operation  for  abscess  of  the  liver.  A  u  tops  y :  appendix  adherent 
to  the  right  broad  ligament  and  surrounded  by  recent  fibrinous  peritonitis.  At  a 
point  where  firmly  adherent,  a  pin  was  found  with  its  head  inside  the  tube  lying 
transversely  to  the  long  axis  of  the  appendix.  The  shaft  and  point  after  passing 
through  the  wall  of  the  appendix  were  surrounded  by  old  adhesions.  The  whole 
of  the  pin  was  irregularly  encrusted  with  calcareous  matter.  Abscesses  of  liver 
(See  Fig.  222.) 


i    « 


Fig. 


223. — Showing   Appendix    Adherent    to    Abdominal    Wall    Following    Discharge  of  Pin.     (June 

9.   1S9<).  Case  35.) 


31.  Keen.  Trans.  Amer.  Sim/.  Assoc,  1898.  Man,  age  twenty-four.  When 
seven  years  old  he  was  troubled  with  dysuria,  and  a  pin  found  in  the  ureter,  which 
he  believed  In-  had  swallowed.  At  operation  a  long  appendix  was  discovered  with 
its  tip  solidly  incorporated  into  the  bladder  ami  discharging  feces  into  that  organ. 

32.  Schooler,  Des  Moines,  1<S!)S.  (Personal  communication.)  Girl,  age  two; 
111  for  several  days.  Localized  swelling  in  region  of  appendix.  Operation: 
incision  and  evacuation  of  pus.  A  pin  found  sticking  through  the  wall  of  the  ap- 
pendix, the  head  remaining  inside.  Appendix  removed,  wound  packed.  Recovery. 
Child  had  swallowed  a  pin  several  months  before. 

:;:'..   Dawbarn.     Ann.  Sun/.,  Oct.,  1S0S.     Child  age  twenty  months.      Opera- 
tion:  the    appendix    found    perforated    by    a    pin.     Child's    father    asserted 
positively  that  the  child  had  swallowed  the  pin  five  weeks  previously.     Death. 
24 


370  ETIOLOGY. 

34.  Ilutiti-.  Philadelphia,  L899.  (Personal  communication.)  Woman  seen  by 
Wm.  Pepper,  Sr.,  who  made  a  diagnosis  of  peritonitis.  Autopsy:  a  pin  was 
found  sticking  through  the  curl  of  the  appendix. 

:;.").  Mitchell.  Johns  Qopkins  Bull.,  1899,  vol.  10,  p.  35.  <iirl.  age  twenty. 
Recurrent  appendicitis.  Operation:  incision  of  abscess.  Patienl  stated 
that  in  the  6rs1  attack,  twelve  Mar-  piv\ iously,  an  abscess  had  discharged  externally 


Fig.  2iM. — Appendix  Pbrfobatbd  hy  a  Four-inch  Shawl-i-in. 

The  he:l'l  of  the  pin  remains  in  the  appendix,  while  the  shaft  tran-fi\c^  the  ileum  ami  the  j,<pint  i>  >urroumied 

t>y  a  small  at>  ee      between  the  ileum  ami  cecum. 

and  a  [tin  had  been  found  in  the  discharge  when  the  wound  was  dressed.  She  remem- 
bered having  swallowed  a  pin  a  short  time  before.  Second  operation  about  a  year 
after  the  first:  removal  of  the  appendix,  which  was  found  adherent  to  the  abdominal 
wall.     (See  Fie.  223. 

36.  Mitchell.  Ibid.,  p.  108.  Negro  boy.  age  seven.  Recurrent  appendicitis. 
Operation:  acute  attack;  evacuation  of  abscess  and  removal  of  appendix. 
Pathological  anastomosis  of  tip  of  appendix  with  ileum,  through  which  a  pin  had 


EXCITING   CAUSES. 


371 


Fig.  225. — Pin  Shown  in  Fig.  224  after  Removal. 
Head  Embedded  in  Concretion. 


passed,  producing  a  perforation  in  opposite  wall  of  ileum.     (See  Figs.  224  and  225.) 
Death  in  less  than  twenty-four  hours  from 
no  discoverable  cause. 

37.  Brooks,  New  York.  1899.  (Per- 
sonal communication.)  Woman. age  fifty- 
four.  Illness  of  a  week,  with  headache 
and  general  pain,  incontinence  of  urine 
and  feces.  Death.  Autopsy:  ap- 
pendix adherent  to  the  right  ovary. 
Just  at  the  centre  of  the  appendix,  where 
there  were  dense  adhesions  to  the  psoas 
muscle,  there  was  a  small  cavity  contain- 
ing pus  and  feces.  The  abscess  com- 
municated with  the  lumen  of  the  ap- 
pendix. Lying  in  the  proximal  portion 
of  the  appendix  with  its  head  near  the 
location  of  the  abscess  was  a  common 
pin  encrusted  with  lime  salts  and  fecal 
matter. 

38.  Wetherill.  West.  Med.  anil 
Surg.  Gas.,  Denver,  Sept.,  1900.  Woman, 
dressmaker.     Tor  fifteen  years  she  had 

had  pain  in  right  iliac  region  with  frequent  severe  exacerbations.     Mass  palpable 

on  posterior  aspect  of  right  broad  ligament.  0  p  e  r- 
ation:  the  tip  of  the  appendix  was  found  adherent 
to  the  right  broad  ligament  below  the  ovary,  the  ad- 
hesions partly  covering  the  tube  and  ovary.  An 
eroded  pin  protruded  from  the  tip. 

39.  Wai.sha.m.  Treatment  of  Appendicitis,  Lon- 
don, 1901.  Localized  abscess  drained,  but  patient 
subsequently  developed  acute  peritonitis.  A  u  - 
topsy:  a  pin  in  the  appendix  had  perforated  the 
wall  of  the  abscess  and  set  up  general  peritonitis. 

40.  Lund,  Boston,  1901.  (Personal  communi- 
cation.) Boy.  age  twelve.  Admitted  on  sixth  day 
of  acute  appendicitis.  Operation:  the  appen- 
dix, red  thickened,  and  edematous,  was  lying  in  a 
small  pus  cavity.  There  was  pus  in  the  pelvis  and 
a  large  pocket  of  pus  below  the  liver.  Excision  and 
drainage.  The  appendix  contained  a  pin,  lying  with 
its  head  in  the  apex  and  its  point  in  a  pocket  which 
projected  from  the  side,  looking  as  if  muscular  con- 
traction hail  forced  the  pin  against  the  side  of  the 
appendix.  (See  Fig.  226.)  Stricture  at  base  of 
appendix.     Recovery. 

41.  Wright,  Augusta,   Ga.,  1902.     (Personal  communication.)     Woman,  seam- 


Fig.  226. — Appendix  Containing  a 
Common  Pin.  Removed  by 
F.  B.  Ldnd,  Boston.     Case  40. 


372  ETIOLOGY. 

stress.  For  a  long  time  severe  pain  in  the  region  of  t In-  appendix.  Finally 
severe  attack  caused  her  t<>  sec  a  physician.  Distinct  tumor  fell  in  the  righl  iliac 
region.  Operation:  a  large  mass  of  adhesions  found,  from  which  the 
appendix  was  enucleated.  A  pin  was  found  projecting  through  the  middle  third  of 
the  appendix,  with  its  head  in  the  lumen.  The  point  of  the  pin  was  thoroughly  cov- 
ered with  adhesions,  showing  the  effort  of  nature  to  proted  the  tissues.     Recovery.* 

42.  Bell.  Montreal  Wed.  Jour.  1902,  p.  765.  Young  man.  Operation  for 
sinus  persisting  after  incision  of  abscess  in  Scarpa's  triangle  communicating  with  the 
open  extremity  of  the  adherent  appendix,  which  contained  a  pin.  The  symptoms 
having  been  indefinite  and  subacute  had  no1  caused  any  suspicion  of  appendicitis. 

13.  Mayo,  Rochester,  Minn.,  1903.  {Personal  communication.)  Appendicitis 
with  abscess.  The  point  of  a  two-inch  shawl-pin  with  glass  head  was  found  pro- 
jecting from  the  side  of  the  appendix,  the  head  being  buried  in  a  mass  of  inflamma- 
tory deposit.     Recovery. 

44.  Houston,  Brooklyn,  1904.  (Personal  communication.)  Child,  girl.  Appen- 
dicitis with  localized  abscess.  The  appendix  was  perforated  and  transfixed  by  a  pin. 
No  recollection  of  swallowing  it. 

15.  Sears,  Syracuse,  1904.  (Personal  communication.)  Child,  twenty  months 
old  (case  of  I".  \Y.  Zimmer,  Rochester).     Pin  in  appendix,  diagnosed  by  A'-ray. 

Iti.  Mudd,  St.  Louis,  1904.  (Personal  communication.)  Male,  twenty-eighl 
years.     Perforative  appendicitis  with  localized  abscess.     A  pin  lying  in  the  appendix. 

Of  the  heavy  bodies  which  sain  access  to  the  appendix,  the  most  common  by 
far  are  shot  or  bullets.  The  earliest  mention  of  these  is  by  Hevin  (Me"m.  de 
VAcad.  royale  de  chir.,  1743,  torn.  1,  p.  460) :  "A  greal  quantity  of  shot  are  some- 
times noticed  collected  in  the  intestines,  especially  in  the  cecum  and  appendix, 
without  having  caused  the  slightest  inconvenience." 

1.  Clark,  Youngstown.  (Personal  communication.)  Hoy,  age  eight.  Died  "\ 
fulminating  appendicitis.  Autopsy:  vermiform  appendix 
contained  a  large,  hard  concretion  with  two  bird-shol  eccen- 
trically placed.     Shot  showed  marks  of  discharge. 

2.  Holmes.     New  Engl.  Quart.  Jour,  of  Med.  mid  Sun/., 

!    ,,   „  P.o-ton,  1NS2-S:;,    vol.    1,   p.  257.      <  >ld    man  dead  of    pneumo- 

TipoT  bullet  '  " 

thorax;  122  robin  shot  in  vermiform  appendix.     No  symptoms 

Fig.     227.— Bullet         referable   to   the   appendix. 

i  o ii mi n o  No-  3_  Ransohoff,    Cincinnati.        (Personal     communication.) 

CLE   US      OF        A 

Concretion.       Young  man.      Recurrent    appendicitis.      Operation:    re- 
Specimbn     from       moval  of  lnillet  surrounded  l>v  concretion.      (See  Fig.  227.) 

[      I  *    \  \  H  fl  If  O  F  F 

Case  3.  4.   Stoxk,   Omaha,  1 901 .      (Pcrsowil  rinnmtuiiattion.)      Mer- 

*  It  would  seem  it  priori  probable  that   seamstresses  and  tailors,  whose  occupation  obliges 

them  to  use  i stantly  I  >■  >t  li  j  >i 1 1 -  and  needles,  and  who  are  eft  en  in  the  habit  ef  putting  them  in 

tlicir  mouths,  would  figure  largely  in  the  reported  cases  of  such  bodies  in  the  appendix.  Tl i i s  is 
not  the  case,  however,  and  the  above  instance,  with  one  other  (So.  38),  are  the  only  ones 
which  have  come  to  my  knowledge. 


EXCITING    CAUSES. 


373 


chant,  age  thirty-five.     Acute  appendicitis.      O 
tained  a   piece  of  solder,   the   poinl   <if  which 
protected  by  omentum. 

5.  Mayo,  Rochester,  Minn.,  1903.  (Personal  communi- 
cation.) Sportsman.  Chronic  appendicitis,  six  years' 
duration.  Operation:  vermiform  appendix  continued 
7  bird-shot. 

6.  Hkxrotix,  Chicago,  1003.  (Personal  communica- 
tion.) Girl,  age  eight.  For  two  years  chronic  appendi- 
citis. Operation:  appendix  showed  chronic  diffuse  in- 
flammation and  contained  bird-shot  embedded  in  concre- 
tion.    (Fig.  228.) 

7.  Beskett.  South.  Calif.  Pract.,  Nov.,  1003,  vol.  18. 
Merchant.  Chronic  appendicitis  lasting  one  year.  Vermi- 
form appendix  4£  inches  long,  distended  with  liquid  feces. 
Contained  4  bird-shot. 

8.  Warren,  Boston,  1003.  (Personal  communication.) 
Woman.      Recurrent    appendicitis.      Vermiform    appendix 

contained  fecal  accumulation  be- 
yond a  point  which  was  obstructed 
by  a  bird-shot  and  a  grape-seed. 
Recovery.     (See  Fig.  220.) 


eration:  the  appendix  con- 
rotruded    through   a    perforation 


Shot 


rape  se  ed 


Other  foreign  bodies  found  in 
the  appendix,  which  have  come 
to  my  knowledge,  are  as  follows: 


Fig.  228.— A  ppesdix 
Containing  \  Bullet. 
The  presence  <if  the 
bullet  (a)  lias  produced 
deep  ulceral  ion  on  i  he  op- 
posite side  of  the  canal  (b). 


1.  Thurnam.    Trans.  Path.  Soc. 
Lond.,    1848-1850,     vol.     1,    269. 

Man,  age  fifty-six.  Patient  had  long  worn  a  truss  for  in- 
cipient inguinal  hernia,  when  he  suddenly  developed  acute 
symptoms  of  abdominal  disease  with  abscess  formation. 
Puncture  gave  issue  to  offensive  pus  and  bubbles  of  gas; 
two  months  later  a  piece  of  bone  j  by  A  of  an  inch  was 
discharged,  after  which  there  was  rapid  recovery.  Death 
occurred  two  months  later  from  another  disease.  Au- 
topsy: showed  the  thickened  appendix  adherent  by 
the  tip  to  the  abdominal  canal. 

2.  Ward.  Trans.  Path.  Soc.  Lond.,  1855,  vol.  7,  p. 
97.  Man.  Attack  of  acute  appendicitis  ending  fatally 
after  an  illness  of  several  days.  Autopsy:  purulent 
peritonitis  occasioned  by  perforation  at  the  base  of  the 
appendix  arising  from  a  small  worn-out  bristle,  apparently 
from  a  tooth-brush. 

3.  Murphy.     Jour.  Am,,:  Med.  Assoc,  Chicago,  1894,  vol.  23,  p.  302.     Woman, 
age  thirty-four.     Attack  of  acute  appendicitis.      Operation:    appendix  large, 


Fir..  229. — Appendix  CON- 
TAINING Shut  AM)  GrAPE- 
BEED. 

The  distal  two-thirds  of 
the  canal  is  tilled  with  fecal 
material  (a).  Removed  by 
.1    ('.   Warren. 


374  ETIOLOGY. 

swollen,  and  tortuous;  no  perforation.  It  contained  an  enterolith  in  which  was 
embedded  a  small  spicule  of  hom-,  the  whole  surrounded  by  pus.     Recovery. 

t.  Ashton.  Med.  Bull.,  I'hila.,  L894,  vol.  16,  p.  85.  Woman,  age  forty- 
eight.  Had  had  abdominal  pain  for  three  years;  referred  to  uterus,  which  was 
curetted  and  cervix  amputated  without  relief.  operation:  exploratory 
laparotomy,  in  which  the  appendix  was  found  adherent  to  the  brim  of  the  pelvis. 
It  was  removed  and  contained  the  fin  of  a  fish,  which  had  caused  circulatory  changes 
and  ulceration  through  pressure.     (See  Fig.  230.) 

5.  Coleman.  N.  Y.  Med.  Rec.,  L895,  vol.  48,  p.  639.  Man,  age  sixty-seven. 
Death  of  nephritis  and  pneumonia.     Autopsy:   in  tin-  dilated  appendix  was  a 

piece  of  1> ■  §  of  an  inch  long  and  A  inch  in  its  broadest  part,  Muni  end  foremost, 

and  embedded  in  mucus.  The  thickened  walls  of  the  appendix  at  the  site  of  the 
foreign  body  were  evidence  of  its  presence  for  a  long  time,  hut  there  were  no  other 
signs  of  inflammation  and  no  history  of  disease  in  the  appendix. 

6.  Mayo,  Rochester,  Minn.,  1903.     {Personal  communication.)     Patient  gave  a 

history  < if  chronic  appendicitis.  Op- 
eration, performed  during  an 
acute  attack:  showed  the  appendix 
containing  a  hone  resembling  the  leg 
bone  of  a  squirrel. 

7.  Gardner,  Baltimore,  1904. 
{Personal  communication.')  Woman, 
age  thirty-six.  Clinical  diagnosis  of 
pelvic  inflammation  following  a  mis- 
carriage. Operation:  the  right 
ovary    was     found    considerably    en- 

F:c  230.— Fish-fin  in  the  Appendix.     Removed  by  larged,     surrounded     bv    dense     adhe- 

W    F    Ashton 

sions,  and  firmly  attached  to  the  ap- 
pendix   at    its    upper  surface.      The 
ovary    and  the  appendix  were   removed,  when   the  appendix    was  found   slightly 
enlarged:  it   contained  several  concretions,  and  a  sliver  of  bone. 

8.  Jay,  Baltimore,  1001.  (['< rstmal  ennnminieaiinn.)  Man,  age  fifty-six. 
First  attack  of  acute  appendicitis,  twenty-four  hours  in  duration.  Operation: 
on  removal  of  the  acutely  inflamed  appendix  it  was  found  to  contain  apiece  of  bone, 
and  part  of  a  fish-fin. 

9.  Goodfellow,  San  Francisco,  1904.  {Personal  communication.)  Man,  age 
forty-four.  Recurrent  appendicitis.  Operation:  the  appendix  was  found 
deep  in  the  pelvis,  embedded  in  a  dense  mass  of  intestinal  adhesions.  It  contained 
a  fish-bone  about  2  cm.  long. 

HI.  Mudd,  St.  Louis,  1904.  {Personal  communication.)  Woman,  with  a  history 
of  chronic  appendicitis.  Operation  :  the  appendix  was  surrounded  by  a  mass 
of  adhesions,  and  at  its  tip  there  was  an  abscess  cavity.  It  contained  a  two-inch 
nail  with  the  point  broken  off. 

Recently  considerable  attention  has  been  directed  to  the  relation  existing 
between   intestinal   parasites    and   appendicitis.     It   has  long  been 


EXCITING    CAUSES.  375 

known  that  enterozoa  are  not  uncommon  occupants  of  the  appendix,  and  in 
numerous  cases  they  have  escaped  through  a  perforation  of  the  appendix  into 
the  peritoneal  cavity.  Their  etiologic  significance  in  the  production  of  appen- 
dicitis is  still  under  discussion.  Dupallieb  (Thhe  de  Paris)  believes  that 
intestinal  worms  cannot  perforate  walls  so  resistant,  especially  if  these 
are  intact;  at  most  they  may  enlarge  an  already  existing  perforation  by  their 
passage,  or  penetrate  one  just  ready  to  appear.  They  can.  however,  act  as 
foreign  bodies  and  determine  an  ulcerative  appendicitis.  Von  Mott  (Lancet, 
1902,  vol.  2,  p.  1211)  attempts  to  make  a  distinction  between  the 
character  of  the  lesions  excited  by  the  different  varieties  of  parasites, 
and  finds  that  lumbrici  seem  to  be  more  often  associated  with  gan- 
grenous appendicitis,  while  the  oxyuris  and  t  r  i  c  h  o  c  e  p  h  a  1  u  s  lead 
to  chronic  inflammatory  conditions.  Reference  to  the  cases  cited  below  shows 
some  confirmation  of  the  view.  While  in  many  instances  the  association 
of  lumbrici  with  perforation  of  the  appendix  may  be  a  mere  coincidence, 
it  is  readily  seen  that  the  mechanical  influence  of  this  parasite  would  be  more 
deleterious  to  the  appendix  than  that  of  the  oxyuris  and  tape-worm, 
and  therefore  the  liability  to  perforation  and  gangrene  would  be  greater.  The 
oxyuris  is  sometimes  found  in  the  normal  appendix  in  large  numbers  and  may 
cause  attacks  of  severe  spasmodic  pain,  simulating  appendicitis.  These  cases 
have  been  carefully  studied  by  Arrore-Rau.y  (Arch,  de  mcd.  des  en f ants, 
December,  1900)  and  by  Mktciixikoff  (Jour,  des  praticiens,  March  23,  1901), 
who  have  urged  the  careful  examination  of  the  stools  for  the  worms  or  ova.  Again, 
however,  these  parasites  are  found  in  the  acutely  inflamed  appendix  and  possibly 
provoked  the  attack.  They  are  most  frequent  in  children.  Thus  Erdman,  in  29 
cases  of  acute  appendicitis  in  children,  in  four  instances  found  from  6  to  30  pin- 
worms  in  the  appendix. 

Ascaris  Lumbricoides. — 1.  Blackadder.  Edin.  Mcd.  and  Surg.  Jour.,  1S24,  vol. 
22,  p.  18.  Man  in  apparent  good  health  was  seized  with  sudden  abdominal  pain  and 
died  in  less  than  four  hours.  Autopsy:  Revealed  nothing  abnormal  except 
the  appendix  markedly  increased  in  length  and  thickness  and  containing  a  large 
lumbricoid  worm,  which  had  forced  its  way  in  until  only  an  inch  of  tail  projected 
into  the  cecum.     No  other  lumbrici  were  found. 

2.  Faber.  Gaz.  mcd.,  1856.  (Quoted  by  Crouzet,  Thesis.)  Case  of  ascarides 
in  the  appendix,  in  which  one  worm  had  passed  through  the  wall  of  the  appendix 
and  entered  a  degenerated  ovary. 

3.  Davaine.  Tniitc  des  entozoaires,  Paris.  1X77.  Case  in  which  the  ulcerated 
appendix  had  perforated  and  allowed  the  escape  of  47  ascarides  into  the  peritoneum. 

4.  Becqueeel.  (Quoted  by  Davaine.)  Child.  Several  ascarides  in  the  peri- 
toneum and  two  caught  in  a  perforation  at  the  extremity  of  the  appendix. 

5.  Tirifahy.  Press*  mcd..  1889.  torn.  16,  p.  89.  Suppurative  perityphlitis, 
phlegmon  of  abdominal  wall.     Incision:   escape  of  a  lumbricus. 

6.  C.   F.   Browkh,   Virginia.      (Pcrsoiud    communication.)      Child,    age    twelve. 


376 


ETIOLOGY. 


Mild  attack  of  appendicitis.  Operation  thirty  hours  after  onset;  removal  of  ap- 
pendix with  portion  of  adherent  omentum.  The  worm,  which  was  still  in  the  ap- 
pendix, was  divided  by  the  scissors  and  half  of  it  then  withdrawn  from  the  cecum. 
The  appendix  was  gangrenous  lor  an  inch  and  a  half  of  its  distal  end.  and  at  one 
poinl  "M  the  verge  of  perforation.     Recovery.     (See  Fig.  231.) 

7.  Natale.  (Cited  by  Metchnikoff.)  Abscess  in  rigid  inguinal  region.  On 
incision  there  was  an  escape  of  pus,  together  with  13  lumbrici  and  the  gangrenous 

appendix. 

8.  Brun.     {Ibid.)     Boy,   age   twelve.     Operation   a   froid.     Alter   removal    of 

the  appendix  a  small  focus  lined 
with  false  membrane  was  found, 
containing  t  he  remains  of  a  luin- 
bricus. 

9.  Bell.  (Loc.cit.)  Casein 
which  a  portion  of  the  appendix 
had  sloughed  off  and  a  large  hnn- 
bricus  lay  in  the  localized  ab- 
scess. 

Oxyuris. — 1.  (J.  H.  H.,  Surg. 
No.  8150.)  Girl,  ape  twelve. 
Two  days'  illness,  beginning  with 
pain  in  the  righl  side,  at  first 
intermittent  and  gradually  in- 
creasing in  severity.  Consti- 
pation. Patient  lay  on  right 
side,  suffering  intense  pain,  face 
Hushed,  respiration  rapid,  tongue 
dry  and  coated, temperature  102° 
!•'.,  pulse  L20,  leucocytes  20,000. 
The  abdomen  was  hard  as  a 
board  and  tympanitic;  tender- 
ness in  the  lower  right  quad- 
rant ,  most  marked  at  H  inches 
to  the  right  of  McBurney's  point. 
Opera  t  i  o  n:  the  peritoneal 
cavity  was  healthy;  the  appen- 
dix was  attached  by  old  adhesions  to  the  colon,  but  retrocecal.  There  was  no 
evidence  of  recent  inflammation,  but  it  was  lull  of  soft  fecal  matter  and  thread 
worms. 

2.  Fkazier.  Univ.  Mai.  Mm)..  1900,  vol.  13,  p.  65.  Girl,  age  two.  Chronic 
appendicitis  for  four  mouths,  following  an  acute  attack.  Operation:  showed 
the  appendix  full  of  oxyurides.  Microscopic  examination  showed  some  infiltra- 
tion of  the  mucosa  and  the  submucosa,  but  no  evidence  of  the  previous  attack. 

3.  Bryant.  Meeting  of  Brooklyn  Surg.  Soc,  May.  1902.  Case  of  appendi- 
citis due  to  presence  of  pin-worm  in  the  appendix.  Removal  of  appendix.  Re- 
covery.    Presentation  of  specimen.     Pin-worm  in  situ. 


Fio.  231. — Appenihv  Containing  a  Li  ubbicus. 
C.  F.  Bkower. 


Removed  i»y 


EXCITING    CAUSES.  377 

4.  J.  Hutchinson,  Jr.  Lancet,  1902,  vol.  2,  p.  837.  Young  woman.  Recurrent 
appendicitis.  Operation:  the  appendix  was  found  crammed  with  living 
oxyurides;   its  walls  were  thickened,  but  not  ulcerated. 

5.  Mayo,  1903.  {Personal  communication.)  Girl.  Attacks  of  pain  in  the 
region  of  the  appendix.  Operation:  removal  of  appendix,  which  con- 
tained a  bunch  of  several  pin-worms.     Recovery. 

6.  Erdman.  N.  Y .  Mid.  Jour.,  March  19,  1904.  lour  cases  of  acute  appendi- 
citis in  children,  in  which  the  appendix  contained  from  (>  pin-worms  in  one  case  to 
30  in  another. 

7.  Bloodgood,  1904.  {Personal  communication.)  Girl,  age  nine  years.  (J.  H. 
H.,  Surg.  No.  9(518.)  Third  attack  of  acute  appendicitis.  Slight  tenderness  in  the 
right  iliac  fossa,  muscular  resistance,  no  definite  spasm,  leucocytes  17,(100.  Opera- 
tion: no  fluid  nor  evidence  of  inflammation ;  the  appendix  was  free,  and  curled 
upon  itself  beneath  the  cecum,  no  constriction  nor  evidence  of  exudate  outside  of 
the  appendix  and  its  mesentery.  Removal  of  the  appendix,  when  it  was  found  to 
contain  a  number  of  small  pin-wTorms.  The  organ  was  normal,  except  for  slight 
injection  of  the  mucous  membrane.     Recovery. 

8.  A.  F.  Kahi/ukoff.  Medizinskoc  Obosrainie,\iA.  (i().  No.  14.  Operation  for 
catarrhal  appendicitis.     In  the  removed  appendix  were  4  living  pin-worms. 

Other  Parasites. — There  are  numerous  instances  on  record  in  which  worms 
of  various  kinds  have  been  found  in  the  inflamed  appendix.  1  cite  the 
following  cases: 

Robb.  Johns  Hopkins  Bull.,  1901,  vol.  3,  p.  23.  Woman,  age  twenty-one. 
Pain  in  back  and  side  and  menstrual  disturbance.  Operation:  left  tube 
and  ovary  adherent  to  the  uterus  and  broad  ligament;  escape  of  several  drams  of 
pus  on  separation  of  adhesions.  Right  tube  and  ovary  adherent  to  pelvic  wall  and 
appendix  adherent  to  the  upper  surface  of  right  ovary,  four  centimetres  of  the  ap- 
pendix removed  and  the  stump  seared  with  the  Paquelin  cautery.  Both  ovaries 
and  tubes  removed.  Examination  of  the  appendix  showed  it  to  contain  a  segment 
of  tape-worm  If)  X  14  mm.  in  size.  Death  in  five  days  from  streptococcus  peri- 
tonitis. 

Metchnikoff.  Jour,  des  praticiens,  March  23,  1901,  No.  12.  Girl.  Peri- 
tonitis. Vermiform  appendix  contained  two  trichocephali,  the  anterior  part  of  one 
of  which  had  penetrated  the  depth  of  the  mucosa  and  had  there  provoked  an  inflam- 
matory reaction. 

Sholler  has  reported  a  case  of  echinococcus  of  the  appendix  associated  with 
echinococcus  of  the  liver,  and  Birch-Hikshfkld  an  instance  of  echinococcus  of  the 
appendix  alone  (Deaver). 

Aireton  relates  a  case  of  Bilharzia  disease  in  which  the  eggs  of  the  parasite 
were  lodged  exclusively  in  the  appendix. 

Pathogenicity  of  Foreign  Bodies  and  Concretions. — The  direct  influence 
of  pointed  bodies  in  producing  inflammation  of  the  appendix  is  evident 
in   some    of   the  cases   cited,  but   it  is  a  remarkable   fact    that   in  most   in- 


378  ETIOLOGY. 

stances,  especially  in  the  case  of  pins,  there  was  proof  that  the  foreign  body 
had  been  present  for  a  long  period  before  this  acute  process  developed,  in  many 
cases  lying  quiescent  in  the  appendix  until  encrusted  with  calcareous  material, 
and,  finally,  determining  the  site  of  a  perforation,  rather  than  inducing  the  acute 
inflammatory  attack,  hi  Bell's  twocases  the  acute  process  was  directly  trace- 
able to  trauma,  the  foreign  body,  in  one  case  a  pin,  being  merely  a  predisposing 
factor.  In  Moriata's  case  there  was  a  history  of  the  pin  having  been  swal- 
lowed a  year  previously  to  the  acute  attack,  which  was  immediately  induced 
by  a  kick  on  the  abdomen. 

In  a  case  described  by  Veron  (Presse  m6d.,  1902)  the  pin  had  been  swal- 
lowed years  before  the  first  symptoms  of  appendicitis  developed.  The  follow- 
ing case,  already  cited  in  brief,  observed  in  the  clinic  of  W.  II.  BALSTED,  shows 
how  a  large  pin  can  harmlessly  travel  the  alimentary  canal,  until  Anally  entrapped 
by  the  appendix,  when  i1  becomes  a  dangerous  object  (see  Case  36,  p.  370): 

A  negro  hoy,  seven  years  of  age,  had  a  history  of  repeated  attacks  of  abdom- 
inal pain  referred  to  the  right  iliac  region  and  accompanied  by  vomiting.  Four 
days  before  admission  he  suffered  from  a  feeling  of  distention,  followed  by  cramps 
and  vomiting.  He  was  found  lying  upon  his  back,  with  his  knees  drawn  up;  the 
abdomen  slightly  distended,  and  the  iliac  region  protected  by  his  hands.  Abdom- 
inal rigidity  and  spasm  were  limited  to  this  region.  The  temperature  was  10^.2°  F. ; 
leucocytes  1 1,000.  <  Operation  disclosed  a  pathological  anastomosis  of  the  tip  of  the 
appendix  with  the  ileum,  through  which  a  4-inch  pin  had  passed,  producing  perfo- 
ration in  the  opposite  side  of  the  ileum,  the  head  remaining  in  the  appendix.  The 
appendix  was  removed,  both  openings  closed,  and  a  gauze  drain  put  in  place. 
Early  the  following  morning  the  child  appeared  to  be  doing  well,  when  he  suddenly 
became  unconscious  and  died  in  a  few  minutes.  Autopsy  revealed  no  definite 
cause  for  death. 

In  the  majority  of  instances,  however,  there  is  evidence  that  the  foreign 
body  excites  a  chronic  inflammatory  reaction  which  ultimately  results  in  an 
acute  process  or  leads  to  abscess  formation.  In  one  case  a  localized  abscess 
was  opened  and  drained,  but  death  resulted  from  general  peritonitis  consequent 
upon  the  perforation  of  the  abscess  wall  by  a  pin.  A  striking  feature  is  the 
frequent  association  of  abscess  of  the  liver  with  the  presence  of  a  pin  in  the 
appendix.  This  was  observed  in  8  cases.  In  these  cases,  with  one  exception, 
the  pin  had  evidently  been  contained  in  the  appendix  for  a  long  time  and  had 
excited  a  chronic  diffuse  inflammation  associated  with  a  slight  purulent  process, 
:i  condition  most  favorable  to  the  production  of  liver  abscess. 

Other  sharp  objects,  such  as  pieces  of  bone  and  fish-fins,  usually  provoke 
the  inflammatory  attack  by  producing  abrasions  of  the  mucosa  and  thus  pro- 
moting the  invasion  of  infective  microbes. 

The  role  of  shot,  bullets,  and  similar  bodies  resembles  that  of  concretions, 
which  is  purely  passive  or  indirect.     Such  bodies  may  occasionally   produce 


EXOITIXC,    CAUSES. 


379 


m 


© 


abrasions  of  the  mucous  membrane,  but,  as  a  rule,  they  act  indirectly  by  ob- 
structing the  lumen,  or  by  causing  pressure  anemia  of  the  appendix  wall  and 
diminishing  the  vitality  of  the  tissue.  These  influences  are  often  latent  until 
brought  into  play  by  some  accessory  factor,  usually  a  marked  physiologic  or 
traumatic  congestion.  The  experiments  of  Roger,  Beaussenat,  Adrian, 
and  others  demonstrate  that  a  smooth,  rounded,  foreign  body  in  the  healthy 
appendix  has  no  influence  in  producing  inflammatory  changes  and  is  usually  soon 
expelled.  Hevix  ( Mcm.de  V Acad.royale de chir .,  1743,  torn.  l,p.460)  called  atten- 
tion to  the  fact  that  a  great  quantity  of  shot  is  sometimes  found  collected  in  the 
intestine,  especially  in  the  cecum  and  appendix,  without  causing  the  least  in- 
convenience. In  one  in- 
stance (p.  372,  Case  2),  122 
robin  shot  were  found  in 
the  appendix  of  an  old  man 
who  during  life  had  had  no 
symptoms  referable  to  the 
appendix.  Concretions  are 
seldom  or  never  found  in 
the  healthy  appendix,  but 
it  is  a  generally  accepted 
opinion  that  the  chronic  in- 
flammatory changes  usu- 
ally present  are  the  cause 
of  the  formation  of  the  con- 
cretion and  not  the  result 
of  its  presence.  Fig.  232 
illustrates  some  of  the  dif- 
ferent kinds  of  foreign 
bodies  which  have  been 
found  in  the  appendix. 

Enterozoa  have  a  two- 
fold influence  in  the  causa- 
tion of  appendicitis:  a  passive  role,  as  in  the  case  of  enteroliths,  and  a 
direct  effect  by  injuring  the  mucosa.  The  general  view,  as  stated  above, 
is  that  the  parasite  does  not  produce  a  perforation  of  the  appendix,  but 
merely  profits  by  the  rapture  which  results  from  a  preformed  ulcer.  'W  bile, 
however,  it  is  not  probable  that  the  parasites  can  penetrate  the  normal 
intestinal  wall,  it  must  not  be  forgotten,  as  emphasized  by  Metchnikofp, 
that  they  can  produce  erosions  of  the  mucosa  and  inoculate  it  with  the 
microbes  with  which  they  are  covered.  Metchnikoff  cites  a  case  of 
Girard's,  who  found  two  trichocephali  in  the  appendix,  the  ante- 
rior part  of  one  being  buried  in  the  depth  of  the  mucosa. 

A  point  of  special  interest  is  that  the  lesions  found  in  the  appendix  often  ap- 


I 


A    G 


a„c 


Fig.  232. — Foreign  Bodies  and  Concretions  in  the  Appendix. 
a  i-  a  fecal  concretion  simulating  a  date-stone;  b,  a  calculus  re- 
sembling a  gall-stone;  c,  a  calculus  with  a  smooth  surface  be-^et  with 
little  projections  which  corresponded  with  crypts  of  Lieberkuhn;  d  and 
e,  shot.  In  the  magnified  pictures,  d'  and  e'.  the  marks  of  discharge 
are  plainly  shown,     f,  concretion  formed  around  a  staple. 


380  ETIOLOGY. 

pear  to  be  quite  inadequate  to  explain  the  severity  of  the  symptoms,  e.  g.,  violent 
pain,  high  temperature,  rapid  pulse,  and  distention,  all  of  which  may  be 
produced  by  living  parasites,  while  the  appendix  is  almost  normal  in  appearance. 


FINAL  CAUSES. 

The  immediate  cause  of  appendicitis  is  always  microbic  infection.  The  normal 
appendix  contains  in  its  canal  the  infective  agents,  which,  innocuous  in  the 
healthy  bowel,  only  wait  the  appearance  of  circumstances  favorable  to  the  exer- 
cise of  their  activities.  The  experiments  of  Rogeb  (Les  Maladies  Injectieuses), 
of  Ki.Krki  (Ann.  de  I'lnstit.  Pasteur,  1899),  and  others  have  shown  thai  it 
is  not  necessary  to  introduce  virulent  bacteria  into  the  appendix  to  pro- 
duce an  inflammation.  The  aseptic  ligature  of  the  bowel,  forming  a  closed 
tube,  and  the  consequent  stagnation  of  the  contents,  increase  the  virulence 
of  the  contained  micro-organisms,  and  when  to  this  is  added  a  slightly  dimin- 
ished resistance  of  the  tissues,  all  the  conditions  necessary  for  an  inflamma- 
tory outbreak  are  at  hand.  As  already  explained,  a  virtual  ms  clos  is  produced 
in  the  appendix  under  various  circumstances.  Moreover,  it  has  been  demonstrated 
by  experiments  that  micro-organisms  which  are  incapable  of  affecting  healthy 
tissue  easily  invade  tissue  slightly  altered  by  traumatism.  Hut  there  are  also 
cases  in  which  there  is  no  evidence  of  obstruction  nor  of  injury.  The  experi- 
ments of  Chastanet  (These  de  Paris,  L897)  showed  that  appendicitis  could  he 
produced  in  the  rabbit  by  making  it  swallow  bacterial  cultures.  The  appen- 
dix is  affected  to  the  same  extent  as  the  rest  of  the  digestive  tube,  but  with 
it,  repair  seems  less  easy.  Bi:w  ssenat  (Rev.  de  gyn.  el  de  chir.  abdom.,  1897), 
by  feeding  rabbits  with  contaminated  meat,  produced  a  severe  intestinal  ca- 
tarrh, and  also  found  in  the  appendix  swelling  of  the  follicles,  small  abscesses 
in  the  mucous  membrane,  and  injection  of  the  organ.  These  changes  were  still 
present  at  a  time  when  the  other  intestinal  lesions  had  healed.  lie  concludes  from 
this  that  the  vermiform  appendix  has  a  very  slight  tendency  to  a  restitutio  <«/ 
integrum.  Reclus  (Sem.  m4d.,  1897,  p.  237)  believes  that  a  propagated 
infection  from  the  cecum  is  answerable  for  a  certain  number  of  cases  of 
appendicitis,  explaining  the  sequence  of  events  by  the  theory  of  stagnation  and 
exalted  bacterial  virulence.  Whereas  in  other  portions  of  the  canal  the  conditions 
are  favorable  for  the  healing  of  the  inflammation,  in  the  appendix,  owing  to  its 
physical  peculiarities,  the  inflammation  is  rendered  more  intense.  Nicolaysen 
(Zeit.  j.  Chir.,  1903,  p.  719),  as  a  result  of  his  experiments  and  from  clinical 
observation,  comes  to  the  conclusion  that  appendicitis  is  primarily  due  to  the 
extension  of  an  infective  enteritis;  Dikilafoy  (Bull,  de  V  Academ.  de  mid., 
Paris,  1904)  believes  that  in  associated  suppurative  cholecystitis  and  appendic- 
itis the  involvement  of  the  appendix  is  secondary,  and  is  due  to  descending  infec- 
tion. He  strongly  insists  upon  the  importance  of  inquiry  for  antecedent  gall- 
stones, and  of  examining  the  gall-bladder  in  every  case  of  appendicitis. 


FINAL    CAUSES.  381 

Appendicitis  as  a  Local  Expression  of  a  General  Infection. — The  fre- 
quent association  of  appendicitis  with  rheumatism  and  other  constitutional 

diseases,  and  the  apparent  occurrence  of  appendicitis  in  the  form  of  small  epi- 
demics, have  forcibly  impressed  many  recent  observers  with  the  idea  of  the  exist- 
ence of  an  etiologic  relationship  between  the  general  infections  and  inflam- 
mation of  the  appendix,  some  writers  going  to  the  extent  of  regarding  all  appen- 
dicitides  as  the  local  expression  of  a  general  infection;  while  others,  again,  noting 
chiefly  its  association  with  influenza,  claim  that  "grip  is  the  true  cause  of  appen- 
dicitis." According  to  Golubof  (quoted  from  Adrian,  Mitt.  a.  d.  Grenz.  des  Med. 
u.Chir.,  1901,  Bd.  7,  p.  407),  on  the  other  hand,  inflammation  of  the  appendix, 
in  the  majority  of  cases,  is  an  infectious  disease  xui  ijcinris, — an  affection  which  is 
peculiar  to  the  appendix  to  the  same  degree  as  angina  follicularis  to  the  tonsils, 
and  dysentery  to  the  colon.  Reclus  and  others,  while  recognizing  the  influence 
of  general  infections,  believe  that  appendicitis  is  not  a  disease  one  and  indivis- 
ible, but  is  produced  by  various  causes,  some  more  of  a  local,  others  more  of  a 
general  character.  In  all  cases  the  predisposing  influences  existing  in  the  appen- 
dix are  important. 

Tripier  and  Paviot  (Sem.  med.,  1899,  p.  73)  came  to  the  conclusion  that 
in  appendicitis,  as  in  the  majority  of  intestinal  lesions,  a  general  infectious 
origin  should  be  more  frequently  recognized.  The  association  maybe  more  or 
less  remote,  as  the  previous  disease  may  have  occasioned  one  or  more  attacks  of 
latent  appendicitis  before  giving  place  to  an  attack  which  manifests  itself  by  the 
characteristic  symptoms. 

The  etiologic  relation  between  appendicitis  and  rheumatism  was  a  matter  of 
frequent  comment  by  the  older  writers,  and  the  theses  which  appeared  on  dis- 
eases of  the  right  iliac  fossa  between  the  years  1N40  and  I860  are  full  of  allu- 
sion to  the  connection  between  the  two.  The  first  suggestion  of  it  in  modern  times, 
which  has  come  to  my  notice,  is  that  of  Sir  James  Grant  (N.  Y.  Med.  Rcc,  1893, 
vol.  11,  p.  609),  who  described  a  case  in  a  girl  of  twelve,  whose  illness  began  with 
pain  in  the  feet,  followed  in  two  days  by  a  typical  attack  of  appendicitis,  and  who 
four  days  later  presented  the  signs  of  acute  rheumatism  with  involvement  of  the 
shoulders  and  elbows.  Since  this  publication  numerous  similar  observations 
have  appeared,  and  seem  to  show  the  existence  of  a  definite  relation  between 
the  two  ailments.  It  is  important  to  note,  as  emphasized  by  Finney  and  Ham- 
burger (Amer.  Med.,  December  14,  1901),  that  the  articular  disease  may  pre- 
cede as  well  as  accompany  or  follow  the  appendical  inflammation.  The  association 
of  tonsillitis  and  appendicitis  has  also  been  established  by  numerous  observations. 
The  frequent  connection  of  tonsillitis  and  rheumatic,  fever  is  now  generally  con- 
ceded. The  tonsillar  affection  may  precede  the  joint  affection  or  may  appear 
simultaneously  with  it.  In  explanation  of  many  cases  of  appendicitis  recent  ob- 
servers have  emphasized  the  analogies  existing  between  the  appendix  and  t ho 
tonsils.  These  analogies  relate  not  only  to  the  anatomic  peculiarities  of  the 
two   structures,  but   also   to  their   predisposition  to  inflammatory   affection, 


382  ETIOLOGY. 

especially  at  a  youthful  age.  In  one  of  Finney's  three  cases  of  appendicitis 
associated  with  rheumatism  there  was  a  history  of  repeated  attacks  of  rheuma- 
tism associated  with  tonsillitis,  and  finally  of  appendicitis  associated  with 
acute  articular  rheumatism  and  tonsillitis.  In  the  surgical  clinic  of  the  .Johns 
Hopkins  Hospital,  there  were  three  instances,  out  of  !»1  cases  of  simple 
acute  appendicitis,  in  which  tonsillitis  preceded  by  a  few  hours  the  onset 
of  the  appendical  symptoms.  The  wider  subject  of  the  relation  of  appen- 
dicitis to  the  general  infections  was  prominently  brought  forward  by  Jala- 
gi  iki;.  who  observed  the  association  of  appendicitis  with  joint  rheumatism 
and  later,  of  appendicitis  following  measles,  mumps,  scarlet  fever,  typhoid  fever, 
and  chicken-pox.  Animal  experimentation  has  demonstrated  that  the  lymphoid 
tissue  of  the  appendix  is  the  seat  of  predilection  for  the  localization  of  infective 
organisms  derived  from  the  general  circulation.  ADRIAN  succeeded  in  producing 
appendicitis  by  injecting  suspensions  of  bacteria  into  the  ear  vein  of  the  rabbit. 
In  these  experiments  microscopic  lesions  were  almost  constantly  demons!  rable  in 
the  mucosa  of  the  appendix  before  either  gross  or  histologic  changes  could  be 
delected  in  other  portions  of  the  intestine. 

The  experimental  proof  of  the  susceptibility  of  the  appendix  to  become  the 
seat  of  a  localized  process  in  general  infections  makes  us  more  ready  to  accept 
the  clinical  evidence.  The  most  frequent  examples  are  found  in  the  association 
of  influenza  and  appendicitis.  In  all  large  epidemics  it  is  repeatedly  observed 
that  the  intestine  is  more  or  less  seriously  injured;  indeed,  as  OSLBH  remarks, 
the  brunt  of  the  catarrhal  affection  may  fall  upon  the  gastro-intestinal  mucous 
membrane.  It  should  not,  therefore,  be  a  matter  of  surprise  if,  in  the  appendix, 
winch  is  already  prepared,  a  more  severe  process  frequently  arises.  During  the 
late  epidemics  of  la  grippe  an  increase  in  the  number  of  cases  of  appendicitis 
and  a  frequent  connection  between  the  two  diseases  has  been  noticed  by  many 
careful  observers.  FINNEY  (loc.  rit.)  observed  an  increase  in  the  frequency 
of  appendicitis  during  a  recent  epidemic  of  la  grippe  and  a  close  relation 
existing  between  the  two  ailments.  In  at  least  six  instances  the  appendical  in- 
flammation appeared  during  or  soon  after  an  attack  of  lagrippe.  SoNNEN- 
burg  considers  it  to  be  an  established  fact  that  during  an  epidemic  of  la  grippe 
inflammation  of  the  appendix  is  much  more  frequent. 

Abbe  (personal  communication)  has  seen  some  cases  of  appendicitis  occa- 
sioned by  influenza  in  which  the  affection  seemed  concentrated  in  the  appendix, 
producing  acute  inflammation,  with  follicular  ulcers  and  some  hemorrhage.  The 
swelling  of  the  regional  lymph  glands  is  characteristic. 

A  further  evidence  of  the  relation  of  the  appendicitis  to  a  general  infection  is  its 
frequent  occurrence  in  epidemic  form.  F.  Franke  mentions  three  cases  of  appen- 
dicitis in  three  brothers  at  one  time;  the  relation  between  the  affection  and  a  then 
prevalent  epidemic  of  influenza  could  not  lie  positively  established.  In  other 
instances,  although  there  was  no  direct  evidence  of  the  relation  of  the  appendical 
inflammation  to  a  specific  infectious  disease,  the  simultaneous  appearance  in  two 


FINAL   CAUSES.  383 

or  more  members  of  the  same  family  was  very  suggestive  of  a  general  infectious 
origin. 

Leudet  (Arch.  gen.  de  med.,  1859,  vol.  104,  pp.  137-316)  describes  cases  of 
perforative  appendicitis  accompanying  varioloid.  The  association  of  appendicitis 
with  scarlet  fever,  measles,  etc.,  has  also  been  frequently  observed.  An  interesting 
example  recently  communicated  to  me  is  as  follows:  A  boy,  eight  years  old, 
was  taken  ill  with  a  severe  attack  of  scarlet  fever  accompanied  with  abscess  of 
the  neck  glands,  and  three  weeks  later  was  operated  on  for  acute  appendicitis. 
Turk,  while  attending  this  case,  developed  an  erysipelatous  throat,  supposed 
to  be  scarlet  fever,  and  fourteen  days  later  had  an  acute  attack  of  appendicitis 
associated  with  exudate.  Blood  from  Turk  was  injected  into  a  rabbit,  and 
on  its  death,  streptococci  were  obtained  from  the  heart's  blood. 

Pouakow  (Cent.  f.  Chir.,  1902,  p.  206)  observed  a  case  of  simultaneous  ap- 
pendicitis and  pneumonia  due  to  the  presence  of  the  staphylococcus.  The 
appendicitis  improved  after  six  or  seven  days,  leaving  a  finger-thick  infiltration. 
The  pneumonia  ended  by  crisis  on  the  ninth  day. 

Another  argument  in  favor  of  this  origin  in  some  cases  of  appendicitis  is  the 
occurrence  of  marked  constitutional  disturbances  preceding  the  appearance  of 
local  symptoms.  In  several  of  our  cases  one  or  two  days'  illness  characterized 
by  headache  and  general  malaise  preceded  the  onset  of  abdominal  symptoms. 
In  one  case  in  a  girl  of  fifteen,  the  illness  began  with  pain  in  the  chest  and  back, 
malaise,  and  slight  cough.  She  slept  poorly,  and  the  next  day  felt  too  ill  to  get 
up,  was  feverish  and  had  no  appetite.  Later  in  the  day  pain  began  in  the  right 
iliac  fossa  and  a  typical  case  of  appendicitis  developed.  In  another  case  there 
was  pain  in  the  back  and  head;  and  in  still  another,  backache  was  present  for 
one  or  two  days  before  the  onset  of  local  symptoms. 

These  clinical  observations  and  the  a  priori  evidence  derived  from  animal 
experimentation  do  not,  however,  warrant  any  positive  deduction  regarding  the 
existence  of  a  causal  relationship  between  the  general  infection  and  inflammation 
of  the  appendix,  and  in  the  absence  of  bacteriological  demonstration  such  deduc- 
tions are  open  to  criticism.  In  frequent  instances  the  pneumococcus 
lias  been  stated  to  be  the  peccant  microbe,  but  so  far  as  I  can  find,  these  obser- 
vations all  lack  the  demonstration  of  the  capsule,  and  in  the  absence  of  this  it 
is  well  known  how  easily  this  organism  is  confused  with  the  streptococcus. 
Adrian  claims  to  have  demonstrated  the  influenza  bacillus  in  a 
peri-appendical  abscess  following  an  attack  of  hi  grippe,  but  unfortunately  no 
description  of  the  morphological  and  cultural  properties  of  the  organism  are 
given.  Further  investigation  along  these  lines  will  doubtless  reveal  the  true 
facts  of  the  case.     To  sum  up,  I  would  say  that : 

1.  A  previous  inflammation  renders  the  appendix  susceptible  to  further 
attacks. 

2.  The  most  important  cause  of  appendicitis  is  digestive  disturbances. 

3.  Acute  and  chronic  entero-colitis  may  be  occasionally  an  exciting  cause. 


:;s|  ETIOLOGY. 

1.   Enteroliths  and   foreign   bodies   usually   play  a  passive  rule.     Pointed 

hodics  ami  enterozoa  may  lie  direct  exciting  causes. 

.">.  The  clinical  evidence  is  in  favor  of  an  intimate  relation  between  appen- 
dicitis and  rheumatic  fever. 

(i.  Animal  experimentation  and  clinical  demonstration  make  it  plain  that 
general  infection  i-  frequently  the  exciting  cause  of  acute  appendicitis. 

7.  It  is  not  yet  determined  whether  the  general  infection  merely  acts  as  an  ex- 
citing  factor  by  preparing  a  suitable  soil  for  the  activities  of  the  intestinal  bac- 
teria, or  whet hci-  the  specific  micro-organism  is  the  direct  cause  of  the  inflamma- 
tion of  the  appendix. 


CHAPTER   XVII. 
CLINICAL  HISTORY. 

SYMPTOMS.     COMPLICATIONS. 

Introductory. — Any  attempt  at  describing  the  symptomatology  of  appen- 
dicitis must  be  preceded  by  the  statement  that  any,  or  even  most  of  its  charac- 
teristic symptoms,  may  be  absent  in  the  beginning  of  any  given  case,  or  even 
throughout  its  entire  course;  and  that  the  clinical  phenomena  of  the  disease  are 
not  a  reliable  criterion  of  the  pathological  changes  in  progress,  as  symptoms  of 
the  most  pronounced  character  accompanying  certain  lesions  in  one  case  may  fail 
to  appear  with  them  in  another.  S.  W.  Gay  characterizes  appendicitis  as  the  most 
treacherous  of  known  diseases,  insidious  in  its  manifestations,  uncertain  in  its 
career,  and  liable  to  sudden  changes  which,  at  any  moment,  may  put  the  patient 
in  a  condition  of  extreme  peril.  It  is  a  matter  of  common  experience  to  find  a 
mild  attack  which  is  apparently  subsiding,  develop  symptoms  of  the  gravest 
significance;  while,  in  other  instances,  the  most  ominous  symptoms  are  some- 
times followed  by  a  speedy  recovery.  The  wider  the  experience  of  the  surgeon 
in  dealing  with  the  protean  forms  of  this  disease,  the  less  confidence  will  he  have 
in  formulating  any  definite  conclusions  regarding  the  interpretation  of  its  indi- 
vidual symptoms,  and  particularly  concerning  their  prognostic  value.  But, 
although  this  fact  should  always  be  borne  in  mind,  it  must  be  added  that 
with  few  exceptions  appendicitis  ought  always  to  be  recognized,  and  we 
may  accept  with  little  reserve  the  dictum  of  DlEULAFOT  that " no  one  should 
die  of  appendicitis."  Moreover,  the  association  of  certain  symptoms  and  their 
preceding  history  produce  a  definite  clinical  picture  in  the  presence  of  which  it  is 
justifiable  to  assume  the  existence  of  certain  lesions;  and  while  it  is  rarely  safe 
to  foretell  the  future  course  of  events  from  the  symptoms  present  at  any  single 
stage  of  the  attack,  it  may  be  possible  to  express  with  some  assurance  an  opinion 
regarding  the  outcome  of  the  disease  if  immediately  arrested  by  operation. 
Thus,  in  the  majority  of  cases,  it  is  possible  to  determine  the  existence  of  acute 
or  chronic  appendicitis,  and  the  presence  or  absence  of  abscess  formation,  or  of  a 
diffuse  or  generalized  peritonitis;  but  there  is  no  symptom-complex  from  which 
we  can  determine  the  exact  amount  of  injury  under  which  the  appendix  itself 
is  laboring,  nor  recognize  whether  perforation  is  impending,  or  a  purulent  peri- 
appendicitis being  successfully  walled  in.  Allowing  for  uncertainty  due  to  these 
facts,  we  may  divide  appendicitis  for  clinical  purposes  into  two  classes — acute  and 
chronic:  and  these  may  be  more  explicitly  considered  according  to  the  presence 
25  3Sf> 


386  CLINICAL    HISTORY. 

or  absence  of  suppurative  peri-appendicitis,  of  general  peritonitis,  or  of  remote 
metastatic   infections. 


SYMPTOMS  OF   ACUTE   APPENDICITIS. 

V.cute    appendicitis   may  nave    a   sudden    onset;  or  ii    may  be 

insidious  in  character,  being  ushered  in  with  symptoms  of  1 lerate  severity 

which  steadily  grow  worse;  or  it  may  possibly  exhibit  occasional  remissions. 
In  :i  number  of  cases  a  feeling  of  general  malaise  precedes  theonsel  of  the  attack. 
The  curly  symptoms  may  include  pain,  tenderness,  rigidity, 
in  us  cle  s  p  a  s  in  ,  u  ;i  u  sea.  v  (i  in  i  t  i  n  g  .  and  eonsl  i  i  m  ional 
disturbance;  distention  and  tumor  may  also  be  present. 
The  time  at  which  these  symptoms  appear,  however,  is  variable,  and  some  of 
them  may  never  occur  at  all.  The  must  constant,  most  characteristic,  and 
most  important  symptoms  of  all  are  pain   and   rigidity. 

Pain. — This  symptom  is  always  present  at  some  stage  of  the  disease,  although 
it  is  occasionally  very  evanescent.  Sometimes  suddenly,  or  sometimes  more  grad- 
ually, the  patient  is  seized  with  sharp  cramp-like  pains  in  the  abdomen.  The 
attack  of  pain  may  come  on  as  suddenly  as  if  the  patient  were  shot .  as  in  a  case  de- 
scribed by  J.  I).  Bryant,  where  a  lieutenant,  when  feeling  perfectly  well,  was 
seized  with  a  sudden  pain  in  the  righl  inguinal  region  so  severe  that  he  could  not 
move.  Poncet  relates  a  similar  case  in  a  soldier,  who  described  the  attack  as 'dike 
tin-  -hot  of  a  gun."  In  one  case  in  the  Johns  Hopkins  Hospital,  a  man.  aged 
twenty,  was  at  work  when  seized  with  abdominal  pain  so  sudden  ami  severe 
as  to  cause  him  to  fall  to  the  ground,  and  in  another  instance  the  patient  fainted 
at  the  first  attack  of  the  pain.  A  sudden  onset  with  acute  abdominal  pain,  the 
patient  being  habitually  in  good  health,  was  noticed  in  43  percent,  of  the  cases  ad- 
mitted to  the  Johns  Hopkins  Hospital.  <  >f  the  remaining  cases,  some  began  with 
slight  symptoms  gradually  increasing  in  severity,  but  in  a  considerable  num- 
ber the  onset  of  acute  symptoms  was  preceded  by  two  or  three  days  of  lassitude 
and  headache,  or  slight  digestive  disturbance.  The  initial  pain  may  from  the 
first  be  located  in  the  right  lower  abdomen,  but  is  commonly  referred  to  some 
other  region.  In  about  one-third  of  the  cases  at  the  Johns  Hopkins  Hospital 
the  pain  began  in  the  right  iliac  fossa.  In  20  per  cent,  there  was  no  definite 
localization,  the  pain  radiating  through  the  whole  abdomen.  The  second 
most  frequent  location  was  in  the  umbilical  region,  and  in  somewhat  fewer  cases 
tin-  primary  pain  was  in  the  epigastrium.  In  one  case  the  attack  began  with  pain 
immediately  to  the  left  of  the  epigastric  region ;  again  it  was  sometimes  referred 
to  the  righl  hypochondrium ;  and  in  two  or  three  instances  pain  in  the  back  was 
the  earliest  symptom.  In  one  instance  the  patient  complained  of  pain  in  the 
right  testicle  for  two  days  before  it  extended  to  the  inguinal  region.  At  the  onset 
the  pain  i<  paroxysmal,  cramp-like,  and  radiating.  It  is  exceedingly  sever©, 
sometimes  indeed  agonizing,  and  the  patient  may  not  be  able  to  straighten  upor 


ACUTE   APPENDICITIS.  -""iSi 

stand  during  the  paroxysms.  There  may  be  complete  freedom  from  pain  in  the 
intervals,  but,  as  a  rule,  a  feeling  of  soreness  persists.  The  paroxysmal  character 
of  the  pain  lasts  from  one  to  several  hours,  and  in  some  instances  continues  through- 
out the  attack;  but  sometimes  after  thelirst  onset,  there  is  a  cessation  of  this  pain 
forseveral  hours,  or  even  as  much  as  a  day.  In  some  cases  the  pain,  at  lirst,  is 
Blight  and  indefinite,  and  then  gradually  increases  in  severity.  It  may  begin  as 
a  vague,  cramp-like  sensation,  or  as  a  diffuse  soreness  increasing  in  intensity,  and 
finally  settling  in  the  right  iliac  fossa.  After  a  few  hours  the  pain  almost  always 
Incomes  localized  in  the  right  lower  abdomen,  and,  as  a  rule,  assumes  a  different 
character,  becoming  less  intense,  but  more  continuous.  Often,  however,  there 
are  still  acute  exacerbations  which  may  be  brought  on  by  movement,  especially 
movement  involving  the  psoas  muscle.  Hence  the  patient  lies  in  the  dorsal 
position,  and  often  with  the  legs  flexed,  in  order  to  favor  the  right  side.  The 
pain  is  also  aggravated  by  the  passage  of  flatus,  by  coughing,  or  by  deep  respi- 
rations. The  site  of  this  later  pain  varies  according  to  the  position  of  the  appen- 
dix. The  greatest  suffering,  however,  is  usually  referred  to  the  iliac  fossa.  It  may 
be  confined  to  a  very  small  area,  or  it  may  be  diffuse,  extending  into  the  groin, 
the  lumbar  region,  or  toward  the  median  line.  In  the  case  of  an  ascending 
retrocecal  appendix,  the  pain  may  centre  in  the  right  hypochondrium,  or  in  the 
posterior  lumbar  region,  sometimes  radiating  towards  the  scapula.  In  one  case 
in  which  this  particular  localization  of  the  pain  was  noticed,  the  tip  of  the  appen- 
dix was  found  in  close  proximity  to  the  base  of  the  gall-bladder  and  a  few  fine 
adhesions  surrounded  the  cystic  duct.  In  a  second  case,  the  appendix  was 
surrounded  by  an  inflammatory  exudate  and  a  tag  of  omentum  was  adherent 
to  the  gall-bladder.  At  other  times  the  chief  pain  is  felt  in  the  hypogastric 
or  pelvic  regions,  in  which  case  the  appendix  is  usually  found  lodged  in  the 
pelvis,  in-  else  an  abscess  has  formed  there. 

B  1  a  d  d  e  r  and  rectal  s  y  m  p  t  o  m  s  are  common,  and  thoracic 
p  a  i  n  is  not  infrequent.  The  latter  is  sometimes  due  to  a  true  pleuritis,  which, 
according  to  AYolbrecht  (quoted  by  Sonnenburg),  is  a  frequent  accompaniment 
of  appendicitis.  In  many  instances,  however.it  is  a  purely  reflex  phenomenon, 
readily  explained  by  the  close  anatomic  connection  between  the  abdominal  wall 
and  the  pleura,  through  the  intercostal  nerves.  In  some  cases  the  pain  is  not  at  any 
time  referred  to  the  region  of  the  appendix,  but  remains  more  or  less  diffuse,  or 
is  confined  to  the  seat  of  the  initial  pain.  Gat,  in  relating  his  own  case,  states 
that  in  every  attack  the  pain  was  definitely  limited  to  the  epigastrium.  Then- 
is  some  discussion  as  to  whether  pain  in  appendicitis  ever  occurs  without  involve- 
ment of  the  neighboring  peritoneum,  and  whether  it  is  always  inflammatory,  or 
may  be  functional  in  origin.  The  experiments  of  Lennander  I  loc.  cit.),  confirmed 
by  the  clinical  observations  of  CusfflNG,  Mitchell,  and  others,  have  demonstrated 
the  absence  of  sensory  nerves  in  the  viscera  and  visceral  peritoneum,  but  have 
shown  that  the  parietal  peritoneum  is  exceedingly  sensitive  to  pain  impressions, 
the  very  slightest  traction  causing  acute  suffering.     They  have  proved  that  the 


;;ss  CLINICAL  insmiiv. 

appendix  may  be  lifted  up,  may  be  compressed  between  Forceps,  and  may  even 
I xcised,  withoul  pain  ;  the  mesentery  also  may  be  ligated  without  the  knowl- 
edge of  the  patient,  if  due  care  is  observed  uoi  to  disturb  its  relations;  but  it 
has  been  experimentally  demonstrated  thai  if  the  slightest  traction  is  brought 
to  bear  upon  the  appendix  or  mesappendix,  exquisite  pain  is  experienced. 
"When  the  ileum  and  ascending  colon  have  a  common  free  mesentery  the  dis- 
comfort  and  pain  from  appendicitis  are  fell  in  the  pit  of  the  stomach,  or  in  the 
para-umbilical  region,  which  is  the  segmental  area  corresponding  to  the  point  of 
origin  of  this  portion  of  the  mesentery.  In  healthy  individuals  there  is  no  sen- 
sation during  the  process  of  digestion,  and  intestinal  tumors  may  progress  with- 
out pain  until  perforation  and  peritonitis  occur.  Strong  intestinal  peristalsis 
may  only  produce  a  sensation  of  rumbling,  but  when  the  parts  of  the  intestine 
which  have  no  mesentery,  or  those  fixed  to  the  parietes  by  peritoneal  reduplica- 

ation  or  adhesions,  are  over-distended,  there  will  he  tension  upon  the  nerves  in  the 
subserosa,  and  each  contraction  will  cause  colicky  pain-."  The  initial  colicky 
pain  in  appendicitis  is  partly  explained  by  the  assumption  that  the  primary 
inflammatory  reaction  excites  abnormal  peristaltic  contractions,  hut  is  probably 
due  to  the  distention  with  flatus  of  the  inflamed  cecal  area,  and  it  is  often  relieved 
by  the  passage  of  flatus. 

'I'lie  secondary  localization  of  the  pain  is  due  to  involvement  of  the  neighboring 
parietal  peritoneum.  The  appendix  is  adherent  to  some  point,  or  the  peri- 
toneum is  inflamed,  or  there  is  a  lymphangitis  or  lymphadenitis  caused  by  the 
infective  microbes  or  their  toxic  products.  Lennander  believes  that  possibly 
the  toxic  substances  from  the  diseased  appendix  may  cause  pain  by  a  direct 
chemical  action  upon  the  cerebrospinal  nerves.  This  pain  lessens  in  intensity 
alter  a  few  hours,  and  in  simple  cases  usually  ceases  in  from  twenty-four  to 
forty-eight.  Occasionally,  it  is  very  evanescent,  disappearing  in  two  or  three 
hours.  An  increase  in  the  local  infection  is  usually  marked  by  the  continuance 
of  the  pain,  which  also  becomes  more  intense.  A  sudden  sharp  pain  after  a 
temporary  subsidence  often  mean-  a  perforation  or  a  beginning  general  infection. 
A  sudden  lull  in  the  local  symptoms,  not  accompanied  with  a  corresponding 
improvement  in  the  general  condition  ("accalmies  traitresses"),  is  an  ominous 
symptom,  and  usually  indicate-  gangrene,  the  rupture  of  a  pus  sac,  or  an  unusu- 
ally virulent  infection.  If  the  pain  again  becomes  generalized,  a  spreading  infec- 
tion of  the  peritoneum  may  he  suspected.  General  toxemia,  on  the  other  hand, 
is  often  marked  by  the  complete  cessation  of  all  pain. 

Tenderness. — Tenderness  on  pressure  possesses  a  significance  of  such  great 
value  that  the  surgeon  hesitates  to  make  a  diagnosis  of  appendicitis  in  its  absence  ; 
nevertheless  it  is  a  symptom  which  must  he  estimated  with  considerable  caution 
and  with  due  allowance  for  the  temperament  of  the  individual.  It  is  easily 
exaggerated  by  neurotic  patients,  hut.  as  pointed  out  by  M.  H.  Richakdson, 
exquisite  tenderness  is  not  easily  feigned,  and,  if  the  patient's  attention  is  di- 
verted, can  he  accurately  gauged.     It  is  a  particularly  important  sign,  in  that  it 


ACUTE    APPENDICITIS.  389 

usually  persists  after  spontaneous  pain  has  ceased,  and  is  present  so  long  as  an 
active  inflammatory  reaction  is  going  on.  A  good  example  of  this  latter  fact  is 
afforded  by  the  following  ease  from  the  surgical  clinic  of  the  Johns  Hopkins  Hos- 
pital. The  patient  had  gone  to  bed  in  his  usual  health,  but  on  rising  he  was  seized 
with  colicky  pain  distributed  over  the  whole  abdomen,  accompanied  with  nausea 
and  a  slight  chill.  In  two  hours  the  pain  became  localized  in  the  right  iliac 
region.  At  the  end  of  seven  hours  after  the  onset  the  pain  entirely  ceased  and 
did  not  return.  When  admitted,  eleven  hours  after  the  beginning  of  the  illness, 
there  was  a  slight  elevation  of  temperature  and  pulse  and  the  abdomen,  although 
not  distended,  manifested  slight  tenderness  over  the  whole  right  lower  quadrant 
and  exquisite  tenderness  over  McBurney's  point,  associated  with  localized 
rigidity  and  muscle  spasm.  There  was  a  leucoeytosis  of  34,000.  Operation 
revealed  an  acutely  inflamed  appendix,  adherent  by  its  tip  and  covered  with 
flakes  of  fibrin.  The  point  of  greatest  tenderness  often  corresponds  exactly  with 
McBurney's  point,  but  frequently  the  most  sensitive  spol  is  a  little  above,  or 
below,  or  to  the  inner  or  outer  side  of  this  area.  It  corresponds  to  the  site  of  the 
appendix  ami  is  most  marked  over  the  diseased  portion.  For  example,  E.  Poxd 
(Med.  Rec,  1898),  in  the  case  of  a  boy  twelve  years  old,  found  slight  rigidity  of 
the  right  rectus  muscle,  more  marked  in  its  upper  half.  There  was  but  slight 
pain  on  deep  pressure  in  the  iliac  region,  but  in  the  posterior  and  miter  part  of 
the  abdomen  there  was  a  swelling  with  extreme  rigidity  of  the  muscles,  ami  at  a 
point  2  cm.  below  the  kidney,  a  spot  which  was  "  as  s<  »re  as  a  boil. ' '  At  operation 
the  point  of  the  gangrenous  appendix  was  found  in  a  position  exactly  corre- 
sponding to  the  sensitive  spot.  Sometimes  there  is  tenderness  on  pressure  in  the 
left  side  of  the  abdomen,  but  this  is  usually  accompanied  with  more  intense 
pain  referred  to  the  region  of  the  appendix.  This  reflex  pain  is  often  an  indica- 
tion of  peritoneal  irritation.  It  is  not  unusual  to  find  that  the  pain  is  not  felt 
while  pressure  is  being  brought  to  bear  upon  the  abdomen,  but  that  on  removing 
the  hand  sharp  pain  ensues.  If  the  appendix  occupies  the  pelvic  position,  tender- 
ness is  sometimes  only  detected  upon  rectal  or  vaginal  examination.  C  u  t  a  - 
neous  hyperesthesia  is  regarded  by  Blos  (Beit.  z.  klin.  Chir.,  Bd. 
32,  p.  420)  as  a  symptom  of  great  importance.  Where  cutaneous  hyperes- 
thesia, muscular  rigidity,  and  localized  or  general  pain  are  present,  periton- 
itis will  always  be  found.  It  is  sometimes  exceedingly  vivid,  making  further 
palpation  impossible. 

Rigidity. — Next  to  pain,  rigidity  is  the  most  reliable  early  sign  of  acute 
inflammation  of  the  appendix.  At  the  outset  it  is  general,  but  soon  after  the 
localization  of  the  infection  it  becomes  limited  to  the  right  side.  G  e  n  e  r  a  1 
rigidity  is  difficult  to  estimate,  for  it  is  often  voluntary,  and  is  commonly 
found  with  simple  intestinal  colic.  Unilateral  rigidity,  on  the 
other  hand,  is  readily  detected,  is  not  easily  assumed,  ami  is  a  definite 
indication  of  underlying  mischief.  Still  more  conspicuous  is  rigidity 
limited    to    a    small    area.     The  value  of  this  symptom  is  thus  tersely 


390  CLINICAL    BISTORT. 

expressed  by  Richardson:  "Rigidity  with  distinctly  localized  pain  strongly 
gests  appendicitis,  with  fever  it  almost  proves  it.  with  tumor  it  fully 
establishes  the  diagnosis."  While,  however,  of  greal  positive  value  and 
almost  constantly  to  be  found  during  the  first  stages  of  an  attack,  it 
sometimes  disappears  early,  and  in  the  most  serious  conditions  may  he 
entirely  wanting  or  so  slight  as  to  be  scarcely  recognizable.  This  is  particu- 
larly true  in  the  presence  of  gangrene,  where  local  tenderness  and  rigidity  may 
both  fail,  and  also  in  many  cases  of  perforative  appendicitis,  where  rigidity 
is  so  slight  and  transient  as  to  escape  observation.  On  the  other  band,  there 
may  be  pronounced  localized  rigidity  in  the  presence  of  very  mild  inflammatory 
processes      The  muscular  tension  is  sometime-  so  pronounced  as  completely 

to  mask  a  tumor  mass  beneath.  As  a  rule,  the  tension  diminishes  as  the  active 
inflammatory  process  subsides  and  the  abdomen  becomes  soft.  If  a  mass  is 
present,  its  outlines  are  then  clearly  perceptible.  Increasing  severity  of  the 
local  infection,  or  the  beginning  of  a  diffuse  peritonitis  are  marked  by  the  return 
and  increase  of  the  muscular  tension,  and  in  extensive  peritonitis  the  abdomen 
usually  becomes  uniformly  distended,  rigid,  and  motionless.  In  some  cases, 
however,  the  abdomen  is  soft  and  natural  in  appearance,  even  in  the  presence 
of  generalized  peritonitis. 

Muscle  Spasm. — Thissymptom  is  less  constant  than  rigidity,but  it  is  observed 
in  the  majority  of  cases  during  the  early  stages  of  the  attack,  anil  its  presence 
is  a  certain  sign  of  an  inflammatory  process.  It  is  a  wholly  involuntary  reaction 
on  the  pari  of  the  muscle,  and  is  best  detected  by  light  palpation.  The  most 
active  muscle  spasm  is  obtained  when  the  appendix  is  in  close  relation  with 
the  abdominal  parietes,  and  when  peritoneal  infection  is  beginning.  In  early 
diffuse  peritonitis,  active  muscle  spasm  may  sometimes  he  found  all  over  the 
abdomen. 

Pain,  tenderness,  and  rigidity  are  rightly  called  the  cardinal 
symptoms  of  appendicitis,  and  they  demand  the  first  and  most  careful  consider- 
ation. There  are,  however,  other  symptoms,  of  fairly  constant  occurrence, 
which  may  have  a  positive  value.  The  most  noteworthy  of  these  are  »;  a  s  t  ro- 
intestinal  disturbance,  elevation  of  temperat u  r  e . 
and  altered  pulse-rate.  General  constitutional  symptoms  also  are 
often  of  greal  significance;  and.  as  pointed  out  by  Federmann  in  describing  peri- 
tonitis, the  genera]  impression  obtained  at  the  first  sight  of  the  patient  is  to  the 
experienced  observer  of  the  greatest  importance,  and  often  leads  to  a  diagnosis 
when  other  signs  are  doubtful. 

Vomiting. — This  is  a  more  or  less  constant  and  prominent  early  symptom 
of  acute  appendicitis.  It  may  or  may  not  lie  associated  with  nausea;  less 
frequently,  nausea  occurs  alone.  There  is  often  a  single  attack  of  vomiting 
at  the  beginning  of  the  attack,  and  it  may  not  recur.  More  frequently  it  begins 
some  hours  after  the  onset  of  the  pain  and  occurs  only  once,  or  is  repeated  two 
or  three  times.     It  rarely  continues  for  more  than  a  few  hours.     In  about  1")  per 


ACUTE    APPENDICITIS.  391 

cent,  of  the  cases  admitted  to  the  Johns  Hopkins  Hospital  there  were  neither 
nausea  nor  vomiting  at  any  time  during  the  attack.  In  several  instances  vomiting 
was  directly  due  to  the  administration  of  medicine,  and  in  other  case-,  again,  it 
occurred  only  after  taking  food.  In  a  few  instances  vomiting  continued  at 
frequent  intervals  for  one  or  two  days,  but  in  favorable  cases  it  was  never  contin- 
uous. If  the  other  symptoms  subside,  vomiting  soon  ceases,  but  with  the  onsel 
of  spreading  or  generalized  peritonitis  it  may  become  persistent  and  uncontrol- 
lable. At  first  the  contents  of  the  stomach  are  ejected,  and  then  bile-stained 
material.  In  unfavorable  cases  the  material  vomited  may  consist  of  dark  greenish- 
black  or  brown  material,  but  it  i<  sometimes  distinctly  stercoraceous.  The  per- 
sistence of  nausea  and  vomiting  is  always  of  grave  significance,  and  an  easy 
continuous  regurgitation,  in  especial,  is,  according  to  Richardson,  a  more  unfav- 
orable symptom  than  occasional  violent  retching.  Hiccough  is  compar- 
atively rare,  but  it  is  occasionally  observed  in  generalized  peritonitis,  or  when  a 
large  abscess  extends  upwards  and  involves  the  diaphragm.  It  is  usually  an 
indication  of  the  involvement  of  the  peritoneal  surface  of  the  diaphragm,  and 
is  sometimes  a  prominent  and  distressing  symptom. 

Constipation. — Constipation  is  present  in  the  majority  of  cases  of  appendi- 
citis. As  before  noted,  it  is  one  of  the  most  constant  events  preceding  the  onset 
of  the  attack,  and  it  usually  persists  until  the  acute  symptoms  are  over.  "When 
the  bowels  have  previously  been  normal,  or  even  when  there  has  been  a  tendency 
to  diarrhea,  constipation  usually  occurs  with  the  appearance  of  acute  symptoms. 
In  a  considerable  number  of  cases  the  initial  violent  intestinal  contractions  cause 
a  sudden  evacuation  of  the  bowels,  and  in  a  small  number,  more  or  less  severe 
diarrhea  may  continue  for  a  day  or  two,  being  then  followed  by  constipation; 
in  other  instances,  diarrhea  persists  throughout  the  entire  attack.  It  is  excep- 
tional to  find  the  bowels  normal  during  the  course  of  the  whole  illness.  Consti- 
pation is  often  very  obstinate,  and  there  may  even  be  complete  obstruction. 
As  a  rule,  the  bowels  are  moved  after  the  first  few  days,  but  continue  more  or 
less  constipated  until  the  end  of  the  attack.  This  symptom,  unfortunately, 
is  often  aggravated  by  the  large  doses  of  opium  so  frequently  required  for  the 
relief  of  the  first  acute  symptoms.  Symptoms  of  complete  obstruction  may  be 
due  to  intestinal  paralysis  caused  by  the  direct  invasion  of  the  intestinal  walls 
by  the  infective  microbes  or  their  toxic  products ;  or  there  may  be  true  obstruc- 
tion due  to  kinks  or  strangulation  produced  by  the  inflammatory  exudate.  The 
characteristic  picture  of  ileus  then  develops:  constant  vomiting,  becoming 
stercoraceous.  and  absolute  constipation  without  the  passage  i  if  either  feces  or  gas. 
The  abdomen  usually  becomes  distended  and  acutely  tender.  With  mechanical 
obstruction  peristalsis  is  often  at  first  plainly  visible,  but  all  intestinal  movements 
cease  when  symptoms  of  peritonitis  develop,  whether  the  obstruction  is  due  to 
adhesions  or  to  primary  intestinal  paresis. 

Hemorrhage. — Hematemesis  has  been  described  by  Treves,  by 
Dieulafoy,  and   by  Matheson  and  others,  and   is   attributed  generally  to  a 


392  CLINICAL    HISTORY. 

toxic  degeneration  of  the  gastric  mucous  membrane  with  erosion  of  small  blood- 
vessels. In  the  rase  reported  by  Matheson  (Brit.  Med.  Jour.,  1901,  vol.  1, 
p.  1201)  the  hemorrhage  was  so  severe  thai  collapse  and  death  occurred  within 

a  U'\\  hours.  Hemorrhage  from  the  ho  we  Is  is  less  rare,  but  by 
no  means  frequent.  It  was  noticed  in  four  cases  oul  of  almost  a  thousand 
admitted  to  the  Johns  Hopkins  Hospital,  [n  one  of  these  cases  then'  was  a  strong 
suspicion  of  tubercular  disease;  in  the  others  no  cause  for  the  hemorrhage  was 
discovered.  In  one  instance  the  hemorrhage,  which  was  preceded  by  diarrhea, 
began  four  days  before  the  patient  was  operated  on  and  continued  until  the 
fifth  day  after.  It  occurred  at  frequent  intervals,  and  was  always  accompanied 
by  severe  griping  pains  in  the  abdomen.  In  another  case  blood,  without  any 
fecal  matter,  was  passed  per  rectum  for  two  or  three  days. 

Temperature. — The  temperature  varies  extremely  in  different  cases.  It 
may  be  very  high  in  the  beginning,  bul  subside  as  rapidly  as  it  arose;  or  there 
may  be  a  gradual  rise,  reaching  the  maximum  in  thirty-six  or  forty-eight  hours; 
while  in  other  cases,  again,  the  evolution  of  the  disease  may  lie  almost  apyretic 

throughout,  even  when  associated  with  the  development  of  a  large  abscess, 
or  in  the  presence  of  a  hopeless  general  peritonitis.  Taken  by  itself,  the  temper- 
ature is  most  unreliable  and  misleading,  bul  in  connection  with  other  symptoms, 

and  at  certain  stages  of  the  attack,  it  may  I f  value  in  showing  the  progress 

of  the  infection.  In  ordinary  cases  the  temperature  is  rarely  high,  often  not 
going  above  100°  !■'..  and  seldom  above  103°  F.  In  a  general  way,  when  asso- 
ciated with  other  slight  symptoms,  a  low  temperature  indicates  a  mild  inflam- 
matory process  and  a  high  temperature  a  more  serious  infection.  But  too  much 
stress  should  not  he  laid  upon  tliis  sign,  as  it  is  often  deceptive.  In  a  recent 
case  at  the  .Johns  Hopkins  Hospital,  a  young  man  walked  into  the  hospital 
with  a  temperature  of  99.4°,  pulse  112;  he  looked  bright,  and  complained 
only  of  slight  soreness  in  the  right  side.  The  attack  had  begun  after  break- 
fast tin'  preceding  morning  with  pain  in  the  epigastrium,  radiating  over  the 
abdomen.  After  an  hour  or  two  the  pain  became  localized  in  the  right  iliac 
fossa,  but  subsided  at  the  end  of  three  hours  and  did  not  return  until  night. 
He  vomited  once,  after  taking  castor  oil,  and  his  bowels  moved  freely.  There  was 
no  further  vomiting  and  no  nausea.  Abdominal  examination  was  negative, 
except  tor  slight  rigidity  on  the  right  side  and  slight  pain  on  deep  pressure  over 
the  region  of  the  appendix.  There  was,  however,  a  leucocytosis  of  26,000,  and, 
notwithstanding  the  low  temperature  ami  absence  of  marked  symptoms, 
FlNNET  decided  upon  immediate  operation.     The  peritoneal  cavity  was  found 

to  ( tain  free  turbid  fluid  and  the  appendix  was  immensely  swollen,  distended 

with  pus.  and  apparently  on  the  point  of  rupture.  The  mucous  membrane  was 
gangrenous.     Recovery  was  uninterrupted. 

In  another  case  the  patient,  a  medical  student,  aged  twenty-five  years, 
was  awakened  with  sharp  abdominal  pain,  chiefly  to  the  left  of  the  epigastrium. 
The  pain  soon  wore  off  and  the  patient  went  to  sleep.     In  the  morning  there  was 


ACUTE    APPENDICITIS.  393 

diarrhea,  relieved,  however,  with  paregoric.  He  vomited  once  in  the  morning 
and  again  in  the  evening.  The  next  morning  he  felt  better  until  after  breakfa-t . 
when  there  was  a  slight  return  of  pain,  and  during  the  day  there  was  considerable 
tenderness.  In  the  evening  he  walked  to  the  hospital  for  advice.  His  temper- 
ature was  then  99.2°  F.,  his  pulse  100;  there  was  considerable  tenderness  in  the 
right  iliac  fossa,  and  slight  distention.  Immediate  operation  showed  the  appen- 
dix distended,  and  covered  with  fibrin ;  there  was  a  gangrenous  patch  at  the  base, 
and  another,  6  cm.  distant,  which  was  perforated.  The  peritoneal  cavity  con- 
tained some  cloudy  fluid.     Recovery. 

In  some  instances  a  simple  catarrhal  appendicitis  is  accompanied  witli  a  tem- 
perature ranging  from  103°  to  104°  F.  A  persistent  high  temperature,  or  a 
renewed  elevation  of  it  after  the  patient  has  begun  to  improve,  is  of  great  signi- 
ficance. A  temperature  continuously  high  from  the  outset  usually  indicates  a 
severe  infection,  with  local  or  metastatic  extension,  or  with  general  intoxication. 
For  example,  a  child  at  the  Johns  Hopkins  Hospital,  agedfour  years,  was  seized 
with  violent  abdominal  cramp,  lasting  some  hours,  after  a  hearty  dinner.  She 
passed  a  comfortable  night,  however,  and  in  the  morning  felt  well,  but  her  tem- 
perature was  104°  F.  and  her  pulse  100.  At  10  a.  m.  the  abdominal  pain  returned 
and  grew  steadily  worse;  the  abdomen  seemed  slightly  swollen  and  tender, 
and  the  temperature  was  105°  F.  A  diagnosis  of  entero-cohtis  was  made  and  an 
oil  enema  given.  During  the  night  the  bowels  moved  three  times  and  she  vom- 
ited once.  The  next  morning  paroxysmal  pain  continued,  referred  by  the  child 
to  the  epigastric  region.  She  lay  with  her  knees  drawn  up.  The  abdomen 
was  swollen  and  tender,  especially  in  the  right  ileocecal  and  lumbar  regions; 
the  tongue  was  dry  and  coated,  the  temperature  104°  F.,  and  the  pulse  140,  the 
leucocytes  32,000.  Operation  revealed  a  general  septic  peritonitis.  The  appen- 
dix showed  an  acute  hemorrhagic  inflammation  with  slight  necrosis  of  the  mucosa. 
Death  occurred  before  the  incision  was  closed. 

On  the  other  hand,  a  general  peritonitis  may  develop  with  practically  no 
elevation  of  temperature.  For  instance,  a  patient  was  admitted  to  the  Johns 
Hopkins  Hospital  in  1891,  with  a  history  of  pain  beginning  the  preceding  morning, 
at  first  localized  in  the  right  iliac  region,  but  later  becoming  general,  and  continu- 
ing until  night,  when  it  was  relieved  by  morphine.  Nausea  was  almost  constant 
and  there  was  frequent  vomiting.  The  bowels  moved  after  an  enema.  On 
admission  there  was  moderate  tympanites  and  general  tenderness,  most  marked 
in  the  right  iliac  region.  Temperature  99°  F.,  pulse  SS.  Frequent  vomiting. 
The  next  day  he  was  more  comfortable,  the  abdomen  not  so  sensitive,  the 
nausea  and  vomiting  diminished,  and  the  pulse  and  temperature  normal.  He 
passed  a  comfortable  night.  At  operation  the  following  morning  the  appendix 
showed  beginning  gangrene  and  there  was  a  general  purulent  peritonitis.  Death 
took  place  on  the  third  day. 

An  encapsulated  abscess  is  usually  accompanied  by  a  continuous  elevation 
of  temperature  with  daily  remissions,  present  from  the  outset  or  beginning  a  few 


394  CLINICAL    HISTORY. 

days  after  the  initial  symptoms.  A  persistent  lever  without  evidence  of  a  gen- 
eral infection  i-  a  fairly  certain  indication  of  the  presence  of  a  focus  of  sup- 
puration.  However,  after  the  active  process  lias  subsided  a  very  large  abscess 
may  exist  with  a  normal  temperature.  In  other  complications,  such  as  abso 
of  the  liver,  septic  phlebitis,  "i  pyemia,  the  temperature  is  usually  high,  ami 
sometimes  remittent  or  even  intermittent  ami  of  the  characteristic  hectic  type. 

Lennandeb  Beit.  :.  klin.  Med.  u.  Chir.,  1895)  calls  attention  to  the  im- 
portance of  observing  the  variations  in  the  relation  between  the  axillary  ami 
rectal  temperatures.  With  early  abscess  formation  ami  in  spreading  abdom- 
inal infection  the  difference  is  sometimes  once  or  twice  greater  than  normal. 
In  very  ill  patients  this  difference  is  sometimes  marked,  ami  may  he  due  to 
the  influence  of  a  neighboring  inflammatory  mass,  but  very  often  ii  is  a  sign  of 
collapse  in  which  there  is  ;1  fall  of  temperature  on  the  surface  of  the  body  and  a 
rise  in  its  interior. 

Chills  are  exceptional  in  cases  of  simple  diffuse  inflammation,  hut  arc 
not  rare  with  more  severe  lesions.  Of  the  case-  of  acute  appendicitis  not  asso- 
ciated with  abscess  or  general  peritonitis,  admitted  to  the  Johns  Hopkins  Hos- 
pital. 1")  pei-  cent.  gave  a  history  of  chills,  and  in  all  of  these,  with  two  exceptions, 
the  appendix  was  gangrenous,  or  perforated,  or  distended  with  juts.  In  the  two 
cases  showing  slight  lesions  there  were  merely  chilly  sensations,  which  in  one  were 
probably  accounted  for  by  the  presence  of  oxyurides  associated  with  high  tem- 
perature. In  three  cases  the  chill  occurred  at  the  onset  of  the  attack;  in  one 
the  patient,  who  had  gone  to  bed  well,  was  awakened  with  a  severe  chill.  .More 
frequently,  the  chill  occurred  several  hours  or  a  day  or  two  after  the  onset.  About 
50  per  cent,  of  the  cases  of  diffuse  or  generalized  peritonitis  were  accompanied  by 
chills,  occurring  in  some  instances  at  the  onset  of  the  appendicitis,  in  others 
with  the  beginning  of  symptoms  of  peritonitis.  A  limited  number  of  the  cases 
associated  with  circumscribed  abscess  gave  a  history  of  chills,  sometimes  occur- 
ring at  the  onset,  or  again  after  the  third  or  fourth  day.  Repeated  chills  oc- 
curring late  in  the  course  of  the  malady  generally  indicate  a  dissemination  of 
the  pyemic  process. 

Pulse. — The  pulse  is  of  greater  importance  than  the  temperature  as  an 
indication  of  the  condition  of  the  patient,  and  as  guide  to  prognosis;  and  more 
especially  the  relation  of  the  pulse-rate  to  the  temperature.  A  very  rapid  pulse 
is  always  a  grave  symptom,  and  a  rapid  pulse  out  of  proportion  to  the  amount 
of  fever  usually  presages  a  fatal  termination.  In  the  majority  of  case-  of  acute 
appendicitis  the  pulse-rate  is  affected  early,  and  while  an  active  process  is  going 
on,  continues  slightly  accelerated,  even  with  a  normal  temperature,  hut  this  is 
by  no  means  a  constant  symptom;  on  the  other  hand,  in  nervous  individuals  and 
children  the  pulse  is  quickened  even  with  simple  functional  disturbances.  As 
the  affection  becomes  localized  and  the  active  process  declines,  the  pulse  becomes 
normal.  The  development  of  a  localized  suppurative  process  is  generally  accom- 
panied by  an  accelerated  pulse-rate,  corresponding  to  the  rise  in  temperature; 


ACUTE    APPENDICITIS.  395 

but  when  the  abscess  is  firmly  limited  and  absorption  diminished,  the  pulse  and 
temperature  are  normal.  AYith  a  spreading  peritonitis  and  beginning  meteorism, 
the  pulse  is  rapid,  full,  and  of  high  tension,  the  high  tension  depending,  according 
to  Lexxaxder,  upon  the  increased  intra-abdominal  tension,  and  the  contraction 
of  the  abdominal  muscles.  As  the  infection  progresses  the  resulting  general  in- 
toxication causes  paralysis  of  the  inhibiting  centre  and  at  the  same  time  directly 
affects  the  heart's  action,  consequently  the  pulse  becomes  rapid,  weak,  and 
irregular.  The  prognosis  in  such  a  case  is  exceedingly  grave,  and  if  associated 
with  a  falling  temperature  is  practically  hopeless.  A  slow  pulse  of  poor  quality 
ma}-  also  indicate  impending  dissolution.  A  good  pulse,  on  the  other  hand, 
may  exist  in  the  presence  of  a  fatal  infection,  and  by  itself  can  never  be  relied 
upon  as  a  guide  to  prognosis  or  diagnosis. 

Tumor. — Amass  is  rarely  recognizable  in  the  early  stages  of  acute  appendicitis 
and  is  not  present  at  any  time  in  cases  of  the  mildest  type,  nor,  as  a  rule,  in  the 
most  severe  forms.  The  presence  of  a  circumscribed  swelling  is  an  indication. 
on  the  one  hand,  of  the  extension  of  the  disease  beyond  the  appendix,  and,  on 
the  other  hand,  of  a  distinct  tendency  toward  its  limitation.  The  inflamed 
appendix  itself,  apart  from  the  surrounding  exudate,  is  seldom  palpable,  and 
even  when  considerably  swollen,  the  rigidity  of  the  overlying  muscle  dining  the 
early  acute  stages  effectually  conceals  it.  As  the  affection  subsides  and  rig- 
idity diminishes,  it  is  sometimes  possible  to  outline  the  exquisitely  tender,  dis- 
tended appendix,  but  very  frequently  it  is  so  deeply  situated  that  even  when 
the  abdominal  walls  are  relaxed  under  an  anesthetic  it  is  not  easily  discovered. 
Often  when  the  appendix  is  supposed  to  have  been  palpated,  at  operation  it  is 
found  in  a  different  and  quite  inaccessible  position,  the  mass  felt  being  probably 
contracted  muscle.  In  some  instances,  however,  a  definitely  outlined  tumor  is 
detected  even  at  the  very  outset  of  the  attack.  With  few  exceptions  this  prove- 
to  be  the  thickened  edematous  omentum  which  has  wrapped  itself  around  the 
appendix,  or  is  attached  by  a  recent  exudation  to  the  most  acutely  inflamed 
portion  of  it.  If  seen  early,  this  omental  tumor  is  more  or  less  freely  movable, 
and  appears  as  a  cylindrical  or  pear-shaped  mass  about  the  size  of  a  fist.  Later, 
it  is  apt  to  become  adherent  to  the  surrounding  structures. 

An  extensive  fibrinous  or  purulent  exudation  is  occasionally  discovered 
shortly  after  the  apparent  onset  of  the  attack,  but  in  most  instances  these  are 
probably  cases  of  insidious  evolution  in  which  the  first  acute  symptoms  are  in 
reality  due  to  the  development  of  the  extra-appendical  process.  In  such  ca<e< 
a  large  abscess  containing  a  pint  or  more  of  pus  may  be  discovered  within  the 
first  twenty-four  hours.  Acute  inflammation  of  the  appendix  persisting  for 
more  than  three  or  four  days  usually  results  in  the  involvement  of  the  surround- 
ing tissues,  and  is  associated  with  a  more  or  less  abundant  exudate,  which  gives 
rise  to  a  clearly  defined  tumor  mass.  The  character  of  the  exudation,  and  hence 
the  physical  peculiarities  of  the  mass,  vary  considerably.  In  some  instances 
the  tumor  may  consist  wholly  of  a  massive  fibrinous  or  sero-fibrinous  exudate, 


396  CLINICAL    HISTORY. 

which  appears  as  an  irregular,  dense,  immovable  thickening.  In  other  cases 
there  is  a  dense  fibrinous  mass,  containing  a  small  incus  of  pus,  or,  again,  a 
large,  fluctuant  abscess  develops,  which  is  usually  globular  and  prominent, 
forming  a  plainly  visible  swelling  in  the  righl  abdomen.  A  purulent  exudate  is 
often  accompanied  by  more  or  less  edema  and  infiltration  of  the  overlying  integ- 
ument. The  inflammatory  mass,  as  a  rule,  is  perfectly  immovable,  but  i)  may 
possess  slight  mobility,  and  in  some  instances— for  example,  when  an  abscess 
develops  between  the  coils  of  intestine,  or  between  the  mesentery  and  the  omen- 
tum, or  between  the  layers  of  the  mesentery — it  may  have  a  well-marked  excur- 
sion.   E.  Laplace  (Jour.  Amer.  Med.  Assoc,  1901,  vol.2,  p.  949)  describes  a  case 

iii  which  a  distinct  tumor,  the  size  and  shape  of  the  kidney,  was  movable  within 
an  area  having  a  radius  of 3  inches  about  the  umbilicus.  This  mass,  which  was 
made  up  of  omentum,  ileum,  colon,  and  mesentery,  was  not  adherent  to  the 
surrounding  peritoneum.  In  its  midst  was  a  foul  abscess  and  the  gangrenous 
perforated  appendix.  A  small  aliscess.  situated  behind  the  cecum  or  ascending 
colon,  may  lie  very  difficult,  and  often  impossible  to  detect,  although  its  presence 
isstrongly  indicated  by  a  long-continued  remitting  temperature.  Percussion  may 
reveal  the  presence  of  a  tumor,  when,  on  account  of  tenderness  and  rigidity, 
palpation  is  unsatisfactory.  The  presenceof  amass  usually  produces  impair- 
ment of  the  normal  tympany,  and  if  superficially  placed,  (here  is  absolute 
dulness  over  the  most  prominent  portion,  then  relative  dulness  passing  into  the 
normal  resonance  aboul  the  margin.  Some  impairment  of  the  normal  sounds 
may  he  found  extending  a  considerable  distance  beyond  the  aliscess  itself, 
being  produced  by  the  presence  of  an  abundant  plastic  exudate  which  mats 
together  the  omentum  and  the  neighboring  intestinal  coils.  The  percussion 
note,  however,  is  not  an  infallible  guide,  for,  on  the  one  hand,  excessive  rigidity 
of  the  abdominal  muscles  may  he  the  cause  of  impaired  resonance;  and,  on 
the  other  hand,  a  small  retrocecal  aliscess.  or  even  one  of  considerable  size, 
may  be  associated  with  a  normal  tympanitic  note  produced  by  the  inter- 
vening dilated  cecum  or  small  bowel.  Again,  with  a  deeply  situated  poste- 
rior abscess  there  may  be  normal  resonance  in  the  anterior  abdomen  and 
dulness  in  the  posterior  lumbar  region.  Sometimes  percussion  over  a  large, 
prominent  mass  may  elicit  a  tympanitic  note  owing  to  the  presence  of  gas  in 
its  interior.  This  phenomenon  may  greatly  confuse  the  diagnosis,  as  in  the 
following  example: 

J.  II.  II.  Sum.  X".  11.770.  Admitted  with  a  history  of  one  week's  illness. 
As  the  patient  was  a  Pole,  a  dear  account  of  its  onset  could  not  be  obtained,  but 
it  was  ascertained  that  there  had  been  no  vomiting,  and  that  the  bowels  had  moved 
two  days  before  admission.  The  tumor  had  been  noticed  for  one  day.  The  ab- 
domen showed  slight  general  fulness  with  visible  peristalsis  in  the  left  lower 
quadrant.     It  was  soft,  and  the  respiratory  movements  free.     In  the  right  iliac 

in  there  was  a  large  prominent  tumor  extending  to  the  median  line  and  from  the 


ACUTE   APPENDICITIS.  397 

level  of  the  umbilicus  to  Poupart's  ligament.  The  mass  was  not  especially  tender 
and  was  tympanitic  on  percussion.  No  peristalsis  was  visible.  It  extended  down 
to  the  right  inguinal  canal,  and  from  the  external  ring  a  finger-like  mass  projected 
which  was  tender  and  hard.  The  right  spermatic  cord  was  thickened  down  to 
the  testicle.  The  temperature  was  103.4°  F.;  the  pulse  120;  the  leucocytes  37,000. 
Operation  was  performed  on  the  supposition  that  there  was  a  strangulated 
hernia.  An  exploratory  incision  was  first  made  in  the  inguinal  region  and  the  mass 
there  found  to  be  the  inflamed,  edematous  spermatic  cord.  Continuing  the  incision 
through  the  edematous  muscle  and  peritoneum,  there  was  an  immediate  escape  of 
a  large  amount  of  gas,  followed  by  very  foul  pus.  The  appendix  was  gangrenous, 
perforated,  and  partly  bound  up  in  omentum.  A  fecal  fistula  developed  six  days 
after  operation,  but  closed  in  two  weeks. 


Distention. — Slight  meteorisin  at  the  outset  is  common  in  cases  beginning 
with  stormy  symptoms,  and  may  be  due  to  constipation  or  to  the  formation  of 
gas.  When  there  is  no  inhibition  of  peristalsis,  the  distention  only  gives  rise  to 
discomfort,  and  as  the  affection  becomes  localized  the  abdomen  usually  assumes 
its  natural  appearance.  With  the  beginning  of  spreading  peritonitis  the  abdomen 
is  often  flat,  and  even  scaphoid.  Distention  usually  occurs  early,  however,  and 
may  be  extreme,  the  abdomen  being  dome-shaped  and  perfectly  motionless.  In 
cases  of  distention  due  to  profound  infection,  no  sound  whatever  is  heard  on 
auscultation.  Richardson  has  observed  that  in  cases  of  great  distention  there  is 
also  at  times  a  serious  interference  with  the  portal  circulation,  the  distended 
intestine  being  dark  red  or  purple,  and  the  portal  radicles  dark  and  prominent. 
In  these  cases  the  heavy  distended  coils  can  be  felt  through  the  abdominal  wall. 
Portal  thrombosis  may  give  rise  to  a  similar  condition.  Marked  distention  may 
also  be  occasionally  observed  in  cases  of  prof ound  toxemia,  without  any  evidence 
of  mechanical  obstruction  or  peritonitis.  Extreme  distention  is  one  of  the 
gravest  symptoms  observed  in  appendicitis,  whether  due  to  a  local  infection, 
to  mechanical  obstruction,  or  to  general  intoxication.  It  is  one  of  the  most  sig- 
nificant signs  of  a  general  peritonitis.  On  the  other  hand,  in  severe  diffuse 
peritonitis  the  abdomen  may  be  flat,  hard,  and  board-like;  or  it  may  be  soft 
and  natural  looking  in  hopeless  cases. 

Jaundice. — This  symptom  occurs  in  a  comparatively  small  number  of  cases 
of  appendicitis,  but  it  may  possess  considerable  significance  as  an  index  to  the 
patient's  condition.  On  the  other  hand,  it  is  sometimes  a  very  misleading  sign, 
because  when  associated  with  hypochondriac  pain,  the  appendical  origin  of  the 
affection  may  not  be  recognized.  Jaundice  in  appendicitis  may  be  of  the  obstruc- 
tive or  non-obstructive  type.  The  former  is  more  common  in  cases  of  chronic 
inflammation,  in  which  adhesions  have  surrounded  the  gall-bladder  and  its 
ducts.  Non-obstructive  jaundice  is  almost  invariably  present  in  cases  of 
appendicitis  accompanied  with  pyemic  abscesses  of  the  liver,  and  is  also  found 
in  cases  with   severe  toxemia.      In  the  former,  owing   to  the  extensive  elisor- 


398  CLINICAL    HISTORY. 

ganization  of  the  liver,  the  jaundice  is  more  intense  than  in  the  latter,  and  is 
also  associated  with  other  signs  of  the  pyemic  process.  The  jaundice  of  tox- 
emia is  usually  slight,  being  often  only  noticeable  in  the  sclera.  It  is  always  an 
unfavorable  sign. 

General  Appearance.  —The  general  condition  of  the  patient  often  affords  valu- 
able information  as  to  the  progress  of  the  disease.  In  cases  of  moderate  severity 
there  is  at  first  an  expression  of  suffering  and  occasionally  an  appearance  of 
slight  shuck,  but  this  soon  passes  off  and  the  patient  lies  quietly,  appears  com- 
fortable, and  does  not  look  very  ill.  The  face  is  usually  a  little  flushed  and  slight 
headache  is  common.  In  more  severe  infection  the  patient  may  look  dull  and 
heavy  and  answer  questions  slowly;  later,  there  is  often  restlessness  and  slight 
delirium.  At  the  outset  the  color  is  good  in  the  milder  forms,  but  with  increasing 
intoxication  the  face  appears  dusky  and  the  skin  is  bathed  with  cold  sweat. 
The  sclera  are  sometimes  slightly  icteric.  General  peritonitis  is 
marked  from  the  outset  by  an  expression  of  anxiety,  but  after  recovery  from 
the  primary  shock  the  patient  for  a  time  may  appear  to  be  improving,  ami 
look  fairly  comfortable  and  well.  When  peritonitis  is  fully  developed,  the 
appearance  is  very  characteristic;  the  expression  is  anxious,  the  face  pinched, 
the  nose  sharp,  the  eyes  sunken,  the  skin  livid,  or  dusky  and  cyanosed,  and 
the  respirations  rapid,  shallow,  and  wholly  costal. 

COMPLICATIONS  OF  ACUTE  APPENDICITIS. 
Suppurative  Peri-appendicitis. — On  account  of  its  frequency,  its  imme- 
diate danger,  and  its  many  troublesome  sequela?,  abscess  formation  is  the  most 
important  complication  of  appendicitis.  Unhappily,  notwithstanding  the 
constant  effort  of  modern  surgeons  to  forestall  thisevent,  il  is  still  present  in  a 
large  proportion  of  the  cases  admitted  for  hospital  treatment,  occurring  in  about 
two-thirds  of  the  acute  cases,  and  in  nearly  one-half  of  all.  Another  fact,  difficult 
of  explanation,  unless  it  be  attributable  to  the  still  too  great  conservatism  of  the 
family  physician,  is  that  the  percentage  of  abscess  cases  admitted  to  the  Johns 
Hopkins  Hospital  during  the  past  three  years  was  practically  the  same  as  during 
the  preceding  ten.  The  individual  symptoms  of  suppurative  peri-appen- 
dicitis have  been  separately  discussed  in  connection  with  the  symptoms  of  acute 
appendicitis,  and  it  only  remains  to  give  a  general  clinical  picture  of  this  condition. 
The  onset  of  an  attack  of  appendicitis  which  goes  on  to  suppuration  differs  in  no 
way  from  an  ordinary  attack.  It  may  be  ushered  in  with  violent  symptoms  or  it 
may  have  a  gradual,  ami  sometimes  very  obscure,  evolution.  In  some  instances 
suppuration  is  present  from  the  outset,  in  which  case  the  initial  symptoms, 
often  unusually  severe,  instead  of  showing  the  usual  decline  at  the  end  of  thirty- 
six  or  forty-eight  hours,  continue  unabated  for  a  longer  time.  The  abdomen  at 
first  is  more  or  less  distended  and  rigid,  so  that  local  signs  of  suppuration  are 
hidden,  but  usually  in  a  few  days,  although  the  general  symptoms  continue 


COMPLICATION'S   OF    ACUTE   APPENDICITIS.  399 

severe,  meteorism  and  rigidity  diminish  and  a  mass  may  be  more  or  less  easily 
palpated.  Sometimes,  while  it  is  impossible  by  palpation  or  percussion  to 
detect  any  evidence  of  a  mass,  the  persistence  of  an  area  of  exquisite  tenderness 
and  the  continued  inclination  to  flex  the  right  thigh  point  to  a  hidden  focus  of 
suppuration.  In  other  instances,  suppuration  develops  later.  The  early  acute 
attack  is  followed  by  a  general  amelioration  of  all  the  symptoms,  and  the  apparent 
improvement  of  the  patient,  when,  in  a  few  days,  a  recrudescence  of  the  fever  is 
noticed,  occasionally  accompanied  with  a  chill.  The  temperature  keeps  high,  or 
assumes  the  characteristic  remittent  type  of  septic  absorption.  At  the  same  time 
there  is  renewed  soreness,  and  sometimes  acute  pain,  in  the  right  side,  while  a 
swelling  develops  more  or  less  rapidly.  In  other  cases,  again,  the  initial  symp- 
toms are  very  misleading,  being  often  not  more  than  a  slight  soreness  in  the  abdo- 
men and  a  feeling  of  general  malaise,  the  patient  in  the  meantime  going  about  as 
usual.  Treves  refers  to  a  case  described  by  Roux,  where  a  man,  aged  forty-two, 
complained  of  some  pain  in  the  right  iliac  fossa,  but  continued  his  work  as  a 
carpenter  for  a  week,  the  bowels  acting  regularly  during  this  time.  On  the  eighth 
day  the  pain  became  worse  and  the  patient  took  to  his  bed,  and  on  the  ninth  day 
■  a  large  perityphlitic  abscess  was  evacuated.  A  similar  case  occurred  in  the 
practice  of  my  associate,  H.  W.  Buckler,  as  follows: 

A  boy,  ten  years  old,  suffered  with  frequent  attacks  of  nausea,  vomiting,  and 
abdominal  pain,  relieved  by  purging  and  dieting.  One  day,  after  a  heavy  dinner,  he 
complained  of  nausea,  and  later  on  he  vomited  his  dinner.  There  was  considerable 
colicky  pain  in  the  abdomen,  but  it  was  not  localized,  and  the  next  day  he  was  much 
better  and  the  pain  was  relieved.  On  the  second  day  he  had  a  dose  of  calomel,  which 
caused  ten  to  fifteen  small  stools,  and  he  complained  of  much  pain  in  defecation  and 
also  in  micturition.  When  seen  on  the  third  day  his  temperature  was  100.5°  F.  and  his 
pulse  90 ;  there  was  no  pain  nor  tenderness  in  the  abdomen  whatever,  his  only  com- 
plaint being  of  difficulty  and  pain  in  micturition,  and  pain  on  defecation.  On  rectal 
examination  a  large  soft  mass,  exquisitely  tender,  was  found  filling  up  the  pelvis. 
During  the  following  night  there  was  rapid  distention  of  the  abdomen  and  the 
temperature  rose  to  102.7°  F.  and  the  pulse  to  110.  Operation  early  the  next 
morning  revealed  a  general  peritonitis,  and  a  large  pelvic  abscess  containing  over 
six  ounces  of  pus.  The  appendix,  which  measured  nine  and  a  half  inches  in  length, 
and  was  situated  in  the  pelvis,  was  completely  gangrenous  and  perforated  at 
the  base. 

After  the  acute  process  has  subsided,  resolution  and  speedy  convalescence 

may  follow,  or  the  abscess  may  remain  more  or  less  quiescent.  It  may  be  present 
for  a  long  time  with  little  constitutional  effect,  but.  as  a  rule,  there  are  the  usual 
manifestations  of  chronic  sepsis,  namely,  emaciation,  progressive  loss  of  strength, 
poor  appetite,  furred  tongue,  and.  ultimately,  complete  exhaustion. 

Generalized  Peritonitis. — This  condition  is  the  most  critical  accompani- 
ment of  the  early  stages  of  acute  appendicitis,  and.  although  less  frequent, 
is  by  no  means  a  rare  accident   in  the  last  stages.     In  some  cases,  symptoms 


400  CLINICAL    HISTORY. 

of  general  peritonitis  are  present  from  the  onset  of  the  attack.  In  other  in- 
stances (the  mure  usual  course)  the  affection  iirst  becomes  localized  in  the  right 
iliac  region,  ami  symptoms  of  the  diffuse  abdominal  infection  develop  later. 
Out  of  about  .">()  cases  observed  at  the  Johns  Hopkins  Hospital.  .'5  showed 
symptoms  of  peritonitis  from  the  beginning,  20  within  the  first  forty-eight 
hours,  and  the  remainder  in  from  two  to  five  days.     :!  cases  gave  a  history 

of  from  nine  to  fourteen  days'  illness,   but    the  exact  date   when    the  symptoms 

of  peritonitis  appeared  was  doubtful.  Whether  arising  early  or  late,  the 
onset  of  general  peritonitic  symptoms  is  usually  very  abrupt,  beginning  with 
intense  radiating  abdominal  pain,  nausea  and  vomiting,  with  a  distinct  chill, 
sometimes  amounting  to  a  severe  rigor,  and  in  a  large  number  of  cases  followed 

by  high  fever.  The  pulse  is  rapid  and  full,  the  expression  anxious,  the 
lace  Hushed,  and  the  respirations  hurried  and  shallow.  There  may  be  more 
or  less  profound  shock,  but,  as  a  rule,  the  patient  soon  rallies.  The  abdomen 
at  this  stage  is  often  flat,  retracted,  and  board-like  in  its  rigidity;  there  is  gen- 
eral tenderness,  marked  cutaneous  hyperesthesia,  and  active  muscle  spasm. 
The  respiratory  movements  are  restricted  or  absent.  The  patient  lies  in  the 
dorsal  decubitus,  usually  with  both  knees  drawn  up.  As  the  peritonitis  be- 
comes established,  the  constitutional  symptoms  become  rapidly  more  pro- 
nounced, the  patient  looks  feverish  ami  shows  more  or  less  hebetude,  the 
tongue  is  dry  and  coated,  nausea  and  vomiting  are  almost  continuous,  there 
is  complete  obstipation,  and  the  respirations  are  very  rapid  ami  altogether  costal. 
The  abdomen  is  now  distended  and  motionless,  its  distention  being  some- 
times especially  marked  in  the  epigastrium.  The  iliac  and  costal  grooves  may 
be  completely  obliterated  and  the  area  of  liver  dulness  greatly  reduced;  there 
may  be  movable  dulness  in  either  Hank,  and  the  abdomen  is  everywhere  exqui- 
sitely tender.  When  the  peritonitis  is  fully  established,  the  patient  is  seen 
to  be  very  ill  at  the  first  glance;  he  looks  septic  and  is  often  very  restless;  the 
facial  expression  is  often  dull  and  stupid  or  there  may  be  a  marked  jacies 
hippocratiea;  the  pulse  is  very  rapid  and  irregular  and  the  fever  may  be  very  high. 
In  one  case  in  the  Johns  Hopkins  Hospital  the  temperature  registered 
100. 2°  I'",  shortly  before  death.  Vomiting  is  usually  continuous  and  is  often 
stercoraceous.  In  other  cases  the  patient  is  found  in  collapse,  the  skin  pallid, 
cyanosed,  and  bathed  in  clammy  sweat;  the  pulse  irregular,  rapid,  and  weak, 
the  temperature  low.  Abdominal  symptoms  at  this  stage  may  be  altogether 
lacking.  In  some  cases,  as  the  climax  approaches,  the  subjective  symptoms 
may  be  those  of  general  well-being,  ami  the  patient  is  convinced  he  is  improv- 
ing. In  the  so-called  fulminating  forms  of  peritonitis,  on  the  contrary,  symp- 
toms of  collapse  may  be  presenl  almost  from  the  first;  the  temperature  may 
never  rise  above  normal  and  it  frequently  becomes  subnormal.  Abdominal 
Symptoms  after  the  first  acute  onset  may  be  inconspicuous.  In  such  cases 
the  overwhelming  intoxication  paralyzes  the  resistance  of  the  organism  from 
the  first  onset,  ami  rapidly  advances  to  a  fatal  termination.     Treves   men- 


COMPLICATIONS    OF    ACUTE    APPENDICITIS.  401 

tions  the  case  of  a  man,  aged  twenty-eight,  who,  after  three  weeks  of  "dyspep- 
sia," during  which  time  he  was  actively  engaged  in  some  outdoor  work,  was 
seized  at  two  o'clock  in  the  morning  with  definite  symptoms  of  perityphlitis. 
When  seen  at  2  p.  M.  on  the  same  day  he  was  cold,  pulseless,  and  dying.  At 
6  p.  ii.  he  was  dead.  Autopsy  revealed  perforative  appendicitis.  In  favorable 
cases  the  severity  of  the  symptoms  gradually  diminishes,  the  temperature 
falls,  the  pulse  becomes  stronger  and  slower,  and  ultimately  convalescence 
is  established. 

Ileus. — The  occurrence  of  intestinal  obstruction  in  the  course  of  acute 
appendicitis  has  already  been  described.  But  it  may  also  occur  as  a  late  com- 
plication, and  very  commonly  appears  when  the  patient  has  fully  recovered 
from  all  evidence  of  the  affection;  or,  again,  it  may  suddenly  develop  in  the 
course  of  an  unsuspected  chronic  appendicitis.  It  is  due  to  the  constricting 
bands  and  adhesions  resulting  from  the  former  acute  or  chronic  peritonitis, 
which  produce  a  sharp  angle  or  twist  in  the  bowel  or  incarcerate  a  portion  of 
intestine  which  has  slipped  under  the  band  of  adhesions.  The  symptoms  are 
very  characteristic:  an  abrupt  onset  with  severe  colicky  pain,  later  becoming 
continuous  and  very  intense;  vomiting,  which  at  first  is  the  contents  of  the 
stomach,  then  bilious,  and  finally  stercoraceous,  and  complete  obstipation 
without  the  passage  of  flatus  or  fecal  material.  The  abdomen  becomes  dis- 
tended, tympanitic,  and  acutely  tender.  The  constitutional  symptoms  are 
severe  and  symptoms  of  collapse  soon  supervene.  In  the  beginning  the  tem- 
perature is  normal,  and  may  continue  so.  The  axillary  temperature  may  be 
subnormal.  The  pulse  is  rapid  and  weak;  the  tongue  is  dry  and  there  is 
incessant  thirst.  Ileus  as  a  post-operative  sequela  is  considered  elsewhere  (see 
Chap.  XXVIII). 

Septicemia. — The  absorption  of  toxins  from  the  primary  focus  of  disease, 
in  other  words,  toxemia,  is  an  accompaniment  of  the  mildest  as  well  as  the 
most  virulent  forms  of  appendicitis,  and  is  a  part  of  the  malady  itself  rather 
than  a  complication.  There  are,  however,  cases  in  which  the  microbes  them- 
selves enter  the  circulation,  and  toxins  are  then  produced  in  the  blood  as  well 
as  absorbed  from  the  primary  seat  of  infection.  In  such  cases  the  removal  of 
the  appendix  is  often  attended  with  very  disappointing  results,  as  the  gen- 
eral infection  pursues  its  typical  course  uninfluenced  by  the  removal  of  the 
primary  seat  of  the  disease.  The  symptoms  of  septicemia  may  set  in  within 
twenty-four  hours  or  they  may  not  appear  until  the  third  or  fourth  day. 
There  is  usually  a  chill  which  may  recur  at  irregular  intervals.  The  tem- 
perature rises  gradually  and  remains  high,  or  is  marked  by  daily  remissions  or 
intermissions;  the  pulse  is  rapid  and  small,  and  there  is  usually  great  pros- 
tration. The  skin  becomes  pale  or  slightly  icteric,  the  tongue  is  dry  and  cov- 
ered with  a  dark  brown  coat.  There  may  be  marked  mental  disquietude 
and  restlessness,  or  the  patient  may  gradually  sink  into  a  typhoid  state 
and  die  in  a  comatose  condition. 

26 


102  CLINICAL    HISTORY. 

Pyemia  complicating  appendicitis  is  characterized  by  the  formation  of  ab- 

3ses  in  various  regions,  due  to  the  transportation  of  septic  emboli  from  the  dis- 
eased area.  The  clinical  picture  of  the  most  important  of  these  metastatic 
abscesses,  thai  is.  abscesses  of  the  liver,  will  be  described  later  in  connection 
with  suppurative  pylephlebitis.  Less  common  areas  of  distribution  are  the 
spleen,  kidneys,  and  lungs.  Cases  have  also  been  reported  of  abscesses  devel- 
oping in  the  brain  and  in  the  parotid  gland.  The  unset  of  pyemia  is  marked  by 
a  severe  chill,  or  rigors,  with  high  temperature  followed  by  profuse  sweats. 
The  chills  may  he  repeated  daily,  or  at  irregular  intervals.  The  lever  may  be 
slight  in  the  intervals  and  there  may  he  periods  of  apyrexia.  There  is  anorexia, 
often  with  nausea  and  vomiting,  and  looseness  of  the  bowels,  the  patient 
usually  becoming  greatly  emaciated.  The  physical  signs  of  abscess  formation 
are  readily  detected  in  the  lungs  and  in  superficial  regions,  as  in  the  parotid 
gland:  in  other  cases  they  max-  escape  observation.  The  disease  may  run  a 
chronic  course,  lasting  for  months,  the  condition  of  the  patient  varying  from 
time  to  time,  hut   the  termination  is  usually  fatal. 

Pylephlebitis,  Liver  Abscess,  Subphrenic  Abscess. — Of  the  reunite  com- 
plications of  appendicitis,  pylephlebitis  and  its  accompaniment,  liver 
a  l><  c  e  s  s.  i-  the  must  to  lie  dreaded.  It  is  usually  a  late  phenomenon,  sometimes 
not  appearing  until  several  weeks  after  the  subsidence  of  the  appendical  affec- 
tion, and  seldom  developing  before  the  end  of  the  first  week  of  the  attack.  It 
may  follow  the  mosl  severe  form  of  appendicitis,  hut  is  commonly  found  as- 
sociated with  the  less  severe,  subacute  cases,  and  often  with  those  of  insidious 
development,  the  masked  cases  of  Treves.  There  are  numerous  recorded  ex- 
amples in  which  the  patient,  who  previously  hail  complained  merely  of  in- 
digestion or  had  been  a  little  oul  of  surts.  suddenly  presented  symptoms  of  the 
acute  liver  affection,  the  appendical  origin  of  which  was  nut  suspected.  The 
chief  points  in  the  clinical  history  are:  severe  pain  in  the  right  hypochondrium 
or  epigastric  region,  and  repeated  rigors,  followed  by  high  fever  and  profuse 
sweats.  Icterus  is  present  in  the  majority  of  cases  and  is  sometimes  pro- 
nounced ;  the  liver  becomes  enlarged  and  painful  and  there  is  rapid  emaciation 
with  progressive  weakness.  Subphrenic  a  lis  cess  may  give  rise  to 
a  clinical  picture  resembling  abscess  of  the  liver.  It  is.  however,  usually  as- 
sociated with  evidences  of  progressive  purulent  peritonitis.  In  addition  to 
the  general  appearance  of  sepsis,  hepatic  tenderness  and  swelling  are  some- 
times conspicuous  features,  hut  rigors  and  jaundice  are  nut  always  so  marked. 
The  liver  is  sometimes  secondarily  affected,  in  which  case  the  symptoms 
are  the  same  as  those  described  in  connection  with  primary  abscess  of  the  liver. 
Peri  p  h  e  r  a  1  t  h  r  o  m  b  o  s  i  s  and  e  m  b  o  1  i  s  m  are  occasional  compli- 
cations of  appendicitis,  but  as  they  occur  more  frequently  as  post-operative 
events,  they  are  described  under  that  head  in  Chap.   XXVIII. 

Lung  and  Pleural  Affections. — The  most  frequent  thoracic  complication 
of  appendicitis  is  pleuritis.     Wolbrecht  (Inc.  cit.)  found  evidence  of  pleural 


COMPLICATIONS   OF   ACUTE    APPENDICITIS.        .  403 

involvement  in  38  per  cent,  of  the  cases  in  Gerhardt's  clinic,  but  this  is  undoubt- 
edly much  too  high  an  estimate  of  its  general  frequency.  There  may  be  a 
simple  sero-fibrinous  pleurisy  or  an  empyema.  The  latter  is  commonly  a  sequel 
of  subphrenic  abscess.  Owing  to  the  presence  of  the  abdominal  affection  the 
pleural  symptoms  may  be  obscure,  but  they  are  frequently  unmistakable,  con- 
sisting of  a  sudden  accession  of  fever,  often  preceded  by  a  chill,  severe  lan- 
cinating pain  in  the  side,  dyspnoea,  and  slight  cough. 

Vesical  and  Renal  Complications. — These  are  comparatively  frequent  events 
in  the  course  of  acute  appendicitis  They  maybe  of  reflex  nervous  origin,  or 
they  may  lie  of  an  inflammatory  nature,  a  pericystitis  or  cystitis 
resulting  from  the  implication  of  the  bladder  wall  in  the  inflammation  of  the 
appendix.  The  reflex  phenomena,  as  a  rule,  are  symptoms  occurring  at  the 
onset  of  the  attacks,  and  are  more  or  less  evanescent.  They  are  not  in  them- 
selves of  serious  import  and  soon  give  place  to  normal  function.  The  most 
common  early  manifestations  are  acute  retention  and  painful  micturition. 
Complete  retention  of  urine  may  persist  from  twenty-four  to  forty-eight  hours. 
In  one  of  the  cases  admitted  to  the  Johns  Hopkins  Hospital  the  attack  of 
appendicitis  began  with  acute,  colicky,  abdominal  pain,  associated  with  pain 
in  the  bladder  and  complete  retention  for  twenty-four  hours.  This  was  re- 
lieved by  catheterization,  and  there  was  no  further  trouble.  Reyxes  (XIII 
Cong,  intern,  de  med.,  Paris,  1901)  describes  a  case  in  which  a  typical  attack 
of  acute  appendicitis  was  accompanied  by  acute  retention  of  urine  lasting  for 
forty-eight  hours.  In  a  case  described  by  Balzer  the  retention,  which  lasted 
for  forty-eight  hours,  did  not  take  place  until  the  fifth  day  of  the  attack. 
These  purely  reflex  phenomena  do  not  necessarily  indicate  that  the  appendix 
occupies  the  pelvic  position.  In  the  majority  of  instances  the  bladder  symp- 
toms are  not  noticed  until  the  second  or  third  day  of  the  attack,  and  are  pro- 
duced by  the  extension  of  the  inflammatory  reaction  to  the  peritoneal  covering 
of  the  bladder,  or  to  the  infection  of  the  deeper  layers.  As  a  rule,  in  these 
cases  the  appendix  occupies  the  pelvic  portion  and  is  in  direct  contact  with  the 
surface  of  the  bladder.  In  other  cases  the  bladder  infection  is  due  to  the  ex- 
tension of  a  suppurative  peri-appendicitis  into  the  pelvis.  The  symptoms  most 
commonly  noticed  are  increased  frequency  and  pain  in  micturition,  tenesmus, 
and,  less  frequently,  retention  of  urine. 

The  vesical  irritability  accompanying  a  simple  pericystitis  sec- 
ondary to  acute  appendicitis  usually  diminishes  with  the  subsidence  of  the 
active  process  and  the  definite  limitation  of  the  appendical  disease.  When 
however,  adhesions  form  between  the  appendix  and  bladder,  dysuria  may  be 
the  most  persistent  and  most  prominent  symptom.  A  good  example  furnished 
me  by  W.  W.  Keex  is  as  follows:  The  patient,  a  medical  student,  aged  twenty. 
gave  a  history  of  frequent  attacks  of  pain  in  the  right  lower  abdomen  which 
began  in  the  region  of  the  appendix  and  extended  downward  and  inward,  caus- 
ing considerable  pain  in  the  bladder  and  in  the  end  of  the  penis.     This  was  so 


lilt  CLINICAL    HISTORY. 

marked  a  feature  of  the  attack  thai  a  skiagraph  was  made  in  order  to  exclude 
the  possibility  of  a  urethral  calculus.  At  operation  the  appendix  was  found 
hanging  over  the  brim  of  the  pelvis  and  attached  to  something  sofl  in  front  of 
it.  presumably  the  bladder. 

A  true  cystitis  is  a  comparatively  infrequent  complication  of  ap- 
pendicitis, bul  it  is  one  which  may  have  the  must  serious  consequences.  An 
intractable  cystitis  may  continue  or  there  may  he  a  persistent  fistula,  or, 
finally,  a  fatal  termination  may  he  the  direct  consequence  of  these  conditions. 
All  grades  of  the  infection  occur,  from  a  mild  diffuse  inflammation  to  a  puru- 
lent infiltration  of  the  bladder  wall,  with  more  or  less  extensive  necrosis  ami 
perforation.  The  classical  symptoms  of  acute  cystitis  are  present,  namely  : 
painful  and  frequent  micturition,  tenesmus,  and  pyuria  or  hematuria.  The 
involvement  of  the  ureter  or  of  the  pelvis  of  the  kidney  in  the  suppurative 
process  may  produce  similar  symptoms.  Cases  have  been  described  in  which 
the  inflammatory  exudate  had  caused  complete  stricture  of  the  ureter  with  a 
consequent  development  of  symptomsof  acute  pyonephrosis.  I  once  operated 
upon  a  woman  for  myoma  of  the  uterus,  and  found,  at  the  same  time,  an  in- 
flamed appendix  densely  adherent  over  the  right  ureter,  which  was  compressed 
by  it  and  completely  strictured.  There  was  also  a  pyonephrosis,  for  which 
nephrectomy  was  performed  later  on.  Dieulapoy  (Presse  mnl..  1898,  torn.  2,  p. 
:M  in  discussing  the  toxicity  of  acute  appendicitis,  has  directed  attention 
to  the  abnormalities  in  the  composition  of  urine  resulting  from  the  absorption 
of  toxic  substances.  The  time  at  which  these  changes  are  observed  varies 
according  to  the  stage  of  the  disease  and  its  severity.  The  most  important 
are  the  presence  of  albumen,  and  of  increased  i  nil  i  can  and  uro- 
bilin, hut,  as  the  infection  progresses,  all  the  symptoms  characteristic  of 
acute  toxic  nephritis  develop,  namely,  diminished  secretion  of  urine,  the  pres- 
sure of  casts,  desquamated  epithelium,  leucocyte.-,  and  hematuria  of  renal  origin 
or  hemoglobinuria.  Albumen  is  present,  as  a  rule,  in  all  acute  febrile  disorders, 
hut,  as  pointed  out  by  Bayet  (These  <le  Pari*.  190]  I,  as  appendicitis  is  at  first  a 
local  affection,  albumen  may  not  be  found  in  it  at  the  outset.  Later  on,  how- 
ever, a-  the  toxins  become  diffused  it  maybe  present  in  abundance.  On  the 
other  hand,  owing  to  the  acute  gastro-intest  inal  disturbances  at  the  outset,  a 
great  increase  in  the  amount  of  indican  may  be  noticed  in  the  first   few  days. 

Fatal  Hemorrhage. — In  a  few  instances  the  erosion  of  a  large  blood-vessel 
occurring  during  the  course  of  an  appendicitis  or  as  a  post-operative  complica- 
tion has  led  to  a  fatal  termination.  Oslek  (Montreal  Hosp.  Gaz.,  1880)  men- 
tions an  instance  of  fatal  hemorrhage  into  the  intestine.  Matheson  (he.  cit.) 
a  fatal   hematemesis,   and    Leudet   (Arch.  gin.  dt    mid.,  vol.   lot.  p.   ltd     a 

e  of  hemorrhage  into  the  arachnoid  space.  The  symptoms  are  those 
commonly  produced  by  internal  hemorrhage,  and.  as  a  rule,  positive  evi- 
dence is  found  in  the  passage  of  blood  by  the  mouth  or  the  rectum. 


CHRONIC   APPENDICITIS.  405 

SYMPTOMS  AND  COMPLICATIONS  OF  CHRONIC  APPENDICITIS. 
Chronic  appendicitis  may  follow  an  acute  attack  or  the  symptoms  may  be 
chronic  from  the  beginning.  There  are  three  fairly  distinct  clinical  forms  of  the 
affection,  although  they  are  not  always  sharply  differentiated  from  one  another: 
the  recurrent  form,  which  is  characterized  by  the  occurrence  of  re- 
peated subacute  or  acute  attacks  with  intervals  of  perfect  freedom  from  any 
clinical  evidence  of  the  disease;  the  chronic  relapsing  form,  in 
which  the  patient  is  never  well  and  is  subject  to  more  or  less  acute  exacerba- 
tions; the  residual  conditions,  which  denote  the  disturbances 
traceable  to  the  influence  of  the  adhesions,  kinks,  etc.,  resulting  from  preced- 
ing acute  or  chronic  inflammatory  attacks.  The  pathological  conditions  under- 
lying any  of  these  forms  may  be  the  source  of  the  so-called  latent  appendicitis 
or  appendicitis  larvata,  in  which  the  infective  process  is  in  a  quiescent  state, 
but  liable  at  any  moment  to  burst  forth  into  activity,  and  often  terminating 
in  acute  perforative  or  gangrenous  appendicitis.  The  clinical  picture  of  chronic 
appendicitis  is  very  varied,  including  in  its  mimicry  almost  all  the  chronic  dis- 
eases to  which  the  abdomen  is  subject.  The  chief  symptoms  are  referred  to 
disturbances  of  the  digestive  functions,  but  pain  and  tenderness  may  be  trou- 
blesome and  serious,  and  in  consequence  of  the  poor  nutrition  and  the  more 
or  less  constant  suffering,  there  may  be  emaciation,  great  weakness  and  lack  of 
energy,  and  often  pronounced  nervous  manifestation-. 

The  more  severe  recurrent  and  relapsing  attacks  are  similar  to  the  acute 
appendicitis  already  described.  Constipation  is  one  of  the  most  con- 
stant symptoms  of  chronic  appendicitis,  and  is  often  most  obstinate.  With  it 
there  are  frequently  more  or  less  marked  dyspeptic  symptoms,  espe- 
cially after  indulging  in  certain  articles  of  food.  Flatulenc  y  is  especially 
common  and  sometimes  seems  to  affect  chiefly  the  ileocecal  region.  It  is  prob- 
ably due  to  a  condition  of  stasis,  owing  to  the  presence  of  adhesions  which  inhibit 
to  some  extent  the  normal  muscular  contractions  (Czerxy).  Loss  of  appetite, 
furred  tongue,  and  nausea  are  frequent  accompaniments  of  the  disturbed  diges- 
tion. Diarrhea  is  less  frequent  than  constipation,  but  is  a  prominent  symp- 
tom in  a  considerable  number  of  cases.  It  is,  perhaps,  most  common  in  the  more 
severe  forms,  in  which  the  patient  is  in  a  state  of  chronic  sepsis.  The  diar- 
rhea may  be  persistent  or  may  alternate  with  periods  of  constipation. 

Pain  and  tenderness  are  characteristic  symptoms  in  the  majority 
of  cases.  The  pain,  as  a  rule,  is  definitely  localized  in  the  right  abdomen,  but, 
as  in  the  acute  affection,  there  is  scarcely  a  spot  in  the  whole  abdomen  to  which 
it  may  not  be  referred.  It  i-  not  often  acute,  being  generally  described  as  a  dull 
ache,  or  merely  a  vague  sense  of  discomfort.  Occasionally,  during  the  height 
of  digestion,  more  or  less  severe  colicky  pain  may  be  complained  of.  or.  again, 
the  pain  may  lie  noticed  only  during  active  exercise.  I  know  of  two  cases  in 
which  the  pain,  which  was  very  severe,  was  always  referred  to  the  rectum,  and  at 


106  CLINICAL    HISTORY. 

operation  the  appendix  was  found  lodged  in  the  pelvis  and  adherent  by  its  tip 
to  tlic  rectum.  In  women  d  y  s  m  e  n  o  r  r  h  e  a  is  often  a  prominent  symptom 
of  chronic  appendicitis,  and  in  every  case  where  dysmenorrhea  follows  an 
attack  of  acute  appendicitis,  the  presence  of  the  chronic  form  of  the  disease 
should  be  suspected. 

The  association  of  m  e  m  1>  r  a  n  <>  u  s  colitis  and  c  h  r  o  n  i  <•  a  p  p  e  n  - 
dici  tis  is  frequently  observed.  Finney  has  especially  noted  its  occurrence 
in  cases  where  there  is  a  thickened,  chronically  inflamed  appendix,  densely 
adherent  to  neighboring  intestines.  Some  writers  have  attributed  the  disease 
of  the  appendix  to  the  influence  of  the  chronic  colitis,  bul  the  evidence  as  a  whole 
is  in  favor  of  the  appendical  origin  of  the  trouble,  the  affection  of  the  colon  being 
secondary.  In  many  instances  acute  attacks  of  appendicitis  have  antedated 
the  appearance  of  symptoms  of  colitis,  and  it  is  a  common  experience  to  find 
that  the  latter  is  entirely  relieved  by  the  removal  of  the  appendix.  Lapetre 
Y.iit.  j.  Chir.,  1903,  p.  498)  describes  six  cases  in  which  coincident  appendicitis 
and  muco-membranous  colitis  were  cured  by  the  resection  of  the  appendix. 


CHAPTER   XVIII. 
DIAGNOSIS. 

DIAGNOSIS.     DIFFERENTIAL    DIAGNOSIS. 

DIAGNOSIS. 

It  is  generally  recognized  that  appendicitis  is  by  far  the  most  common  inflam- 
matory disease  of  the  abdomen,  especially  in  men  under  thirty  and  in  children  of 
both  sexes.  Sudden  pain  in  the  right  iliac  fossa  with 
local  tenderness  an  d  m  uscular  rigidity  are  significant  i  if 
the  disease  in  the  large  majority  of  instances;  there  are,  however,  many  cases 
of  obscure  development  in  which  the  cardinal  signs  of  appendicitis  are  very 
inconspicuous;  moreover,  as  pointed  out  by  Mynter  (Appendicitis,  1898),  few 
diseases  present  so  many  stages  each  characterized  by  a  different  set  of  symp- 
toms, while,  on  the  other  hand,  every  one  of  these  cardinal  symptoms  may  be 
absent,  or,  if  present,  may  indicate  some  other  affection.  The  physician  may 
not  see  the  patient,  in  fact,  he  rarely  does  see  him,  during  the  initial  stage  of  t  he 
attack,  and  by  the  time  the  disease  comes  under  observation,  the  acute  symptoms 
have  subsided  and  the  pain  become  localized — it  may  be  in  the  right  iliac  fossa, 
but  frequently  at  a  point  remote  from  the  normal  position  of  the  appendix;  again, 
in  other  instances,  the  pain  may  have  ceased  entirely,  and  there  may  be  a  lull 
in  all  the  symptoms,  which  in  one  case  denotes  improvement  and  in  another 
marks  the  onset  of  grave  complications.  It  is  not  only  the  combination  of  symp- 
toms and  their  appearance  in  a  distinct  order,  however,  which  indicate  the  char- 
acter and  progress  of  the  malady,  but  the  impression  made  upon  the  trained 
mind  by  their  combination  and  progress.  In  every  case,  therefore,  a  clear  de- 
scription of  the  onset  and  course  of  the  attack  should  be  obtained,  the  subjective 
and  objective  symptoms  carefully  weighed,  and,  what  is  often  of  the  utmost  im- 
portance, the  history  of  the  patient  in  regard  to  previous  attacks  of  appendic- 
itis investigated.  Finally,  when  the  diagnosis  has  been  made  in  this  manner  by 
direct  evidence,  it  should  be  confirmed  by  a  general  examination  of  the  patient, 
in  order  to  verify  it  by  exclusion  and  thus  avoid  the  chagrin  of  operating  for  a 
supposed  appendicitis,  and  finding  a  case  of,  perhaps,  thoracic  disease  with  pro- 
nounced abdominal  manifestations.  The  recognition  of  appendicitis  in  the 
majority  of  cases  is  easy,  but  it  is  often  difficult,  and  sometimes  impossible,  to 
determine  the  grade  of  the  infection  and  the  extent  of  the  complications;  more- 
over, in  the  early  stages  of  the  disease  there  are  no  symptoms  nor  combination  of 

407 


Ills  DIAGNOSIS. 

symptoms  by  which  the  probable  course  of  events  can  be  foretold  with  any 
certainty. 

In  the  presence  of  the  cardinal  symptoms,  namely,  sudden,  acute 
abdominal  pain,  tenderness  on  pressure  over  or  near 
McBurney's  point,  and  localized  muscular  rigidity, 
the  diagnosis  of  appendicitis  is  justified  in  the  majority  of  cases.  Confirmatory 
symptoms,  such  as  nausea  and  vomiting,  constipation  or  diarrhea,  elevation  of 
temperature  and  acceleration  of  pulse,  make  the  diagnosis  more  secure,  and 
the  presence  of  tumor  puts  it  beyond  doubt. 

It  must  be  remembered,  however,  thai  the  position  of  the  appendix  is  very 
variable,  and  it  may  lie  directed  to  almost  any  point  in  the  abdomen,  hence  the 
local  symptoms  are  sometimes  referred  to  the  region  of  the  gall-bladder,  to  the 
left  side  of  the  abdomen,  to  the  hypogastric  region,  or  to  the  pelvis.  H.  L. 
NlBTERT  (Interstate  Mid.  Jour.,  March.  1903)  records  a  case  in  which  there  was 
an  entire  absence  of  local  symptoms  referable  to  the  right  iliac  region,  but  there 
was  dulness  in  the  left  iliac  fossa.  A  median  incision  showed  a  transposition 
of  the  viscera  and  a  gangrenous  appendix  on  the  left  side.  In  a  case  referred  to  by 
Fowler,  operative  interference  was  delayed  on  account  of  the  absence  of  symp- 
toms referable  to  the  right  iliac  fossa,  although  the  clinical  picture  suggested  an 
acute  perforative  appendicitis.  At  the  autopsy  the  appendix  was  found  lying 
to  the  left  of  the  median  line,  about  an  inch  above  the  level  of  the  umbilicus  and 
fixed  in  this  position  by  a  short  mesocolon.  Hypogastric  pain  with  tenderness 
and  rigidity  on  both  sides  is  very  characteristic  of  pelvic  appendicitis. 

During  the  early  stages  of  the  disease— a  period  when  operative  interference 
could  save  almost  every  case  it  is  unfortunately  impossible  to  determine  whether 
there  is  a  simple  inflammation  which  will  undergo  speedy  resolution  without 
surgical  treatment,  or  if  the  case  will  proceed  to  the  most  dangerous  extrem- 
ities,  gangrene  or  suppuration  being  already,  perhaps,  at  hand.  In  general  it 
may  be  said  that  if  the  attack  begins  with  slight  or  moderate  local  symptoms  ami 
mild  constitutional  disturbance,  it  is  probably  an  ordinary  catarrhal  or  a  diffuse 
inflammation,  and  if  the  symptoms  do  nol  increase  in  severity,  bul  show  a  gen- 
eral improvement  at  the  end  of  twenty-four  to  thirty-six  hours,  recovery  will 
take  place  without  further  complications.  A  sudden  onset  with  violent  pain, 
high  temperature,  and  rapid  pulse,  on  the  other  hand,  usually  indicate  a  more 
immediately  dangerous  condition,  and  in  some  cases  there  is  reason  to  believe 
thai  the  firsl  acute  symptoms  are  due  to  beginning  peritonitis,  the  result  of  per- 
foration, gangrene,  or  a  virulent  infection.  Intense  agonizing  pain  at  the  onset  is 
often  due  to  a  perforation.  Collapse  symptoms,  whether  appearing  in  the  begin- 
ning or  later  in  the  attack,  if  the  patient  does  not  quickly  rally,  are  significant  of  a 
virulent  infection  with  general  intoxication.  As  a  rule,  the  patient  is  not  seen 
during  the  earliest  stages  of  the  disease,  several  hours  or  even  a  day  elapsing 
before  a  physician  is  summoned  ;  much  importance  therefore  attaches  at  this  time 
to  the  following  quest  ions:    Are  the  symptoms,  both    general  and 


DIAGNOSIS.  409 

local,  subsiding;  are  they  becoming  more  severe;  or 
are  they  apparently  stationary?  If  after  twenty-four  hours 
the  patient  is  seen  to  be  getting  worse  instead  of  better,  complications  may 
usually  be  expected.  If  after  thirty-six  to  forty-eight  hours  there  is  continuous 
high  fever  and  a  correspondingly  rapid  pulse,  suppuration  or  a  general  infection 
is  strongly  suggested.  A  rapidly  increasing  pulse-rate,  especially  when  out 
of  proportion  to  the  degree  of  fever,  is  one  of  the  most  urgent  symptoms, 
usually  signifying  gangrene,  or  perforation  with  beginning  peritoneal  infection, 
or  a  general  septicemia.  A  sudden  accession  of  local  pain  usually  indicates  a 
dangerous  change  due  to  the  beginning  of  perforative  peritonitis,  and  if  the 
pain  again  becomes  diffuse,  especially  if  it  is  associated  with  shock,  there  is 
probably  a  sudden  effusion  into  the  general  peritoneal  cavity.  A  lull  in  the 
local  symptoms,  particularly  in  the  presence  of  an  increasing  pulse-rate,  is  often 
due  to  caiijirene  or  perforation  of  a  pyo-appendix,  and  is  soon  followed  by  more 
or  less  quickly  developing  peritonitic  symptoms,  unless,  indeed,  the  patient  suc- 
cumbs to  a  rapidly  fatal  toxemia. 

Suppurative  Peri-appendicitis. — This  condition  is  recognized  by  the  con- 
tinuance or  the  recrudescence  of  high  fever  and  rapid  pulse  after  the  second 
or  third  day,  associated  with  pronounced  local  symptoms  and  the  absence  of  any 
evidence  of  general  peritonitis.  The  most  positive  proof  of  a  circumscribed 
abscess  is  the  presence  of  a  tumor.  It  must  be  remembered,  however,  that  a 
mass  may  be  due  to  a  plastic  exudate,  gluing  together  contiguous  structures,  or 
to  the.adherent  rolled-up  omentum,  or  it  may  even  be  simulated  by  rigidity  of  the 
abdominal  muscles.  On  the  other  hand,  a  small  focus  of  suppuration  may  exist 
without  giving  rise  to  a  palpable  tumor.  At  a  later  stage,  when  the  abscess  is 
firmly  encapsulated,  constitutional  disturbances  diminish  owing  to  the  lessened 
absorption,  and  the  pulse  and  temperature  may  become  normal.  Fluctuation 
is  usually  not  detected  in  the  beginning  of  the  attack,  and  often  not  at  all.  In  the 
case  of  a  pelvic  abscess,  however,  as  in  one  instance  in  my  own  practice,  a 
fluctuating  tumor  may  sometimes  be  detected  on  the  second  day.  In  the  absence 
of  distinct  local  signs,  continuous  fever  may  depend  upon  some  remote  metastatic 
infection  such  as  pylephlebitis  or  liver  abscess.  But  these  complications 
usually  occur  later  in  the  course  of  the  disease,  and,  as  a  rule,  are  attended  with 
unmistakable  symptoms. 

Progressive  Peritonitis. — The  onset  of  spreading  peritonitis  is  indicated 
when  the  local  pain,  tenderness,  and  rigidity  again  become  generalized  and  the 
pulse-rate  increases.  Confirmatory  signs,  such  as  chills,  persistent  nausea 
and  vomiting,  elevation  of  temperature,  especially  in  the  rectum,  and  an 
anxious  expression,  usually  appear  early,  but  much  valuable  time  will  be  wasted, 
and  the  present  deplorable  failure  of  operative  interference  in  this  class  of  cases 
will  continue,  if  such  pronounced  symptoms  are  waited  for,  because  when  the 
classical  signs  of  a  fully  established  peritonitis  are  present,  the  case  is  practically 
hopeless.     Peritonitis  occurs  most  commonly  between  the  second  and  fifth  days, 


11(1  DIAGNOSIS. 

an  interval  which  is  the  danger  period  of  appendicitis.     It  must  be  remembered, 

however,  thai  the  first  sympl s  of  the  attack  may  be  those  of  a  beginning 

peritonitis. 

Obscure  and  Masked  Forms  of  Appendicitis. — There  are  certain  cases 
of  appendicitis  which  are  not  attended  with  any  of  the  usual  clinical  mani- 
festations, and  the  patient  may  pursue  his  usual  avocation  until  suddenly  evi- 
dences   of    some    remote    sequela    develop,    the    a|ipendical   origin   of    which    is 

not  suspected.  A  striking  example  is  related  by  Treves,  in  which  a  middle- 
aged  gentleman,  after  being  a  little  out  of  sorts,  was  seized  with  pain  in  the  hepatic 
region  attended  by  a  rigor  and  a  subsequent  rise  of  temperature.  The  rigors 
were  repeated,  the  fever  became  very  high,  jaundice  supervened,  and  it  became 
evident  that  the  patient  was  suffering  from  pylephlebitis  and  liver  abscess. 
No  mischief  could  be  detected,  however,  in  any  pari  of  the  abdomen  except 
about  the  liver.  In  fourteen  days  he  died,  when  the  liver  was  found  riddled 
with  abscesses;  the  appendix,  which  was  disorganized  ami  filled  with  pus,  had 
evidently  been  the  seat  of  long-standing  disease.  In  other  cases  the  clinical 
phenomena  are  vague  and  misleading,  the  symptoms  never  being  referred  to 
the  right  iliac  region  and  not  being  acute.  There  is  a  feeling  of  general 
malaise,  with  loss  of  appetite,  furred  tongue,  constipation  or  loose  bowels,  and 
a  little  swelling  and  tenderness  of  the  abdomen.  The  patient  may  be  able  to 
walk  and  even  to  work  while  an  appendicitis  is  progressing  and  a  large  ab- 
scess developing.  Frrz  (Amer.  Jour.  Med.  Sci.,  1886,  vol.  92,  p.  331)  men- 
tions the  case  of  a  sailor  who  was  at  work  rolling  barrels  of  flour  until 
the  day  of  his  admission  to  the  hospital.  He  had  then  a  prominent  fluctuant 
tumor  extending  along  the  outer  half  of  Poupart's  ligament.  The  gradual 
evolution  of  the  malady  with  slight  pain,  swollen  and  slightly  tender  abdomen, 
and  the  absence  of  localized  symptoms  may  strongly  suggest  tubercular  peri- 
tonitis. X.  ('.  Powell  (personal  communication)  operated  upon  a  man  who 
had  been  ill  for  three  years,  being  about  one-half  of  the  time  confined  to  bed, 
with  supposed  tubercular  peritonitis.  After  removal  of  the  inflamed  appendix 
his  health  was  completely  reestablished.  Similar  cases  are  mentioned  by  Bboca 
(These  de  Lyon,  1901).  In  other  cases,  again,  the  patient  suddenly  develops 
collapse  symptoms,  or  general  septicemia  appears  without  any  pronounced 
abdominal  symptoms.  A  history  of  preceding  attacks  of  appendicitis  is  an 
important  aid  in  the  diagnosis  of  these  obscure  cases.  It  must  also  be  borne  in 
mind  that  many  obscure  cases  of  liver  al>sce<s,  abscess  of  the  lung  or  pleura, 
and  cases  of  cryptogenetic  septicemia  are  of  appendical  origin. 

Examination  of  the  Patient. — The  characteristic  posture  of  the  patient 
in  appendicitis  immediately  arrests  the  attention.  Almost  without  exception  he 
assumes  the  dorsal  decubitus  with  the  right  leg  slightly  flexed,  and  exhibits 
an  evident  desire  to  avoid  all  movement.  I  once  saw  the  case  of  a  young  girl 
where  the  only  prominent  symptom  was  the  characteristic  attitude.  There  was 
no  spontaneous  pain,  and  firm  pressure  over  the  region  of  the  appendix  did  not 


DIAGNOSIS. 


411 


elicit  any  tenderness  nor  perceptible  spasm.  The  tem- 
perature was  99°  F.,  the  pulse  80.  There  was,  how- 
ever, a  history  of  acute  abdominal  pain  on  the  preceding 
day,  and  when  I  saw  her  she  was  lying  on  her  back  with 
the  right  knee  drawn  up,  plainly  avoiding  all  movement 
whatever.  In  the  afternoon  of  the  same  day  the  tem- 
perature was  99.8°  F.,  and  the  pulse  slightly  acceler- 
ated. Operation,  performed  immediately,  revealed  a 
deeply  situated  appendix,  which  was  swollen,  turgid, 
almost  mahogany  colored,  and  covered  with  flakes  of 
greenish  lymph. 

Abdominal  examination  must  include  inspection, 
palpation,  percussion,  and  auscultation. 

Inspection  . — The  abdomen  in  ordinary  cases 
appears  normal  or  it  may  be  slightly  meteorismic.  It 
i-;  usually  symmetrical,  but  there  is  sometimes  slight  ful- 
ness in  the  right  lower  quadrant,  possibly  due  to  some 
distention  of  the  cecum,  and  the  right  iliac  grooA'e  may 
not  be  so  well  marked  as  the  left.  A  distinct  promi- 
nence indicates  an  encapsulated  abscess.  The  respira- 
tory movements  are  usually  free  in  all  parts;  limitation 
of  the  respiratory  movements  in  the  right  lower  abdo- 
men is  evidence  of  a  localized  peritonitis,  and  absence 
of  all  abdominal  movement  shows  a  general  peritoneal 
infection. 

Palpation  . — Before  palpating  the  abdomen,  the 
head  and  thorax  should  be  somewhat  elevated,  the 
knees  and  thighs  slightly  flexed,  and  the  patient  made 
to  relax  thoroughly.  He  must  then  be  put  off  his 
guard  by  questions,  while  at  the  same  time  the  hand  is 
passed  over  the  entire  abdomen,  the  right  iliac  region 
being  avoided,  and  a  little  pressure  made  here  and 
there  to  discover  any  points  of  tenderness,  while  at  the 
same  time  a  definite  idea  is  obtained  as  to  the  general 
condition  of  the  abdominal  walls.  The  confidence  of 
the  patient  being  thus  gained,  the  surgeon,  still  dis- 
tracting his  attention,  makes  a  few  rotary  movements 
with  slight  pressure  witli  the  finger-tips  over  the  right 
iliac  fossa,  noticing  if  there  is  any  complaint  of  pain, 
and  also,  especially,  any  rigidity  or  spasm  of  the  muscle ; 
ainl  then,  without  delay,  before  the  patient  has  time  to 
guard  against  the  attack,  he  makes  deep  pressure  with 
one  or  two  fingers  down  into  the  head  of  the  cecum 


Fig.  233. 
Piezometer  u-cd  r,t  meas- 
ure the  amount  of  pressure 
necessary  to  produce  pain,  as 
well  as  the  force  required  to 
overcome  the  resistance  of  the 
muscular  spasm  a-  compared 
with  the  opposite  side.  The 
piezometer  affords  an  objec- 
tive method  of  demonstrat- 
ing the  presence  of  pain  and 
resistance.  The  barrel  con- 
tains a  spring  and  both  cyl- 
inder anil  rod  are  graduated. 
(One-half  natural  size.) 


412 


hi  V.GNOSIS. 


and  McBurney's  point,  when,  if  there  is  any  inflammatory  trouble,  the  patient 
at  once  cries  ou1  and  catches  his  hand.  In  doubtful  cases  of  appendicitis  the 
tactual  sense  may  be  supplemented  and  confirmed  by  the  use  of  the  instru- 


FlO.   234. 
Showing  the  method  of  using  the  piezometer  to  determine  the  amount  of  pressure  neeilei! 
The  ^liiliriK  wheel  indicates  the  depth  of  the  depression  produced  by  a  given  amount  of  pressure,  and  the  mus- 
cle spasm  i-  estimated  when  comparison  is  made  with  the  corresponding  point  <-n  the  opposite  side. 


ment.  piezometer,   shown  in  Figs.  233  and   234.     This  may  be  used  as 

an  algesimeter  to  determine  the  amount  of  pressure  necessary  to  elicit  tender- 
ness over  the  appendix,  and  may  also  be  used  to  estimate  the  degree  of  rigidity 


DIAGNOSIS.  413 

in  the  right  iliac  fossa  by  comparing  the  rigidity  of  the  right  and  left  rectus 
muscles.  For  example,  with  a  pressure  of  500,  the  button  on  the  end  of  the  rod 
may  indent  the  abdominal  wall  so  that  the  wheel  registers  1  cm.  on  the  right  side, 
while  at  a  corresponding  point  on  the  left  side  it  registers  1.5  cm.  or  more.  In 
this  way  the  rigidity  is  demonstrated  beyond  a  question  and  no  allowance 
need  be  made  for  difference  in  tactual  sense.  At  the  same  time  the  graduate!  1  n  k  1 
indicates  the  amount  of  pressure  necessary  to  elicit  pain.  [Joints  Hopkins  IIi>.<- 
pital  Bulletin,  Sept.,  1904.) 

In  acute  cases,  and  also  in  patients  with  thick  abdominal  walls,  it  is  seldom 
possible  to  palpate  the  appendix.  Moreover,  the  attempt  to  do  so  is  not  without 
danger,  as  the  distended  or  gangrenous  appendix  may  easily  be  ruptured.  In 
chronic  appendicitis  the  thickened,  erect  appendix  is  plainly  felt.  In 
order  to  detect  the  appendix  according  to  the  method  described  by 
Edebohls,  the  examiner  seeks  the  margin  of  the  right  rectus  muscle,  on  the 
line  between  the  navel  and  the  anterior  superior  spine  of  the  ilium.  Then  with 
light  steady  pressure  the  fingers  are  introduced  under  the  margin  of  the  rectus 
until  the  common  iliac  artery  is  distinctly  perceptible.  The  appendix,  as  a  rule  is 
felt  just  outside  the  artery,  its  insertion  being  about  an  inch  distant  from  the 
vessel  while  its  tip  often  crosses  it.  A  perityphlitic  exudate  may  at  first  be  masked 
by  the  rigidity  of  the  abdominal  wall,  but  as  the  acute  process  subsides,  it  is 
usually  easily  recognized.  Examination  under  ether  will  often  reveal  the  swollen 
appendix  or  the  presence  of  an  exudate  which  could  not  otherwise  be  detected. 
This  method,  however,  is  seldom  indicated  except  as  a  guide  in  making  the  incision. 
The  examiner  must  always  bear  in  mind  the  risk  of  rupturing  the  appendix  or  an 
encapsulated  abscess,  an  accident  which  has  more  than  once  occurred. 

In  some  obscure  cases  a  valuable  aid  in  examining  the  patient,  described  by 
B.  McMonagle  (personal  communication),  is  the  pain  elicited  by  holding  the 
fingers  firmly  over  the  normal  site  of  the  appendix  and  requiring  the  patient 
to  contract  the  right  psoas  muscle  by  flexing  the  leg,  held  rigid  at  the  knee,  on 
the  body.  A  rectal  examination,  and,  in  married  women,  a  vaginal  examination 
as  well,  should  never  be  omitted,  as  it  serves  not  only  to  exclude  affections  of  the 
pelvic  organs,  but  is  often  valuable  in  locating  the  appendix  and  in  revealing  its 
diseased  condition.  In  children,  particularly,  the  inflamed  appendix  may  be 
palpated  per  rectum  even  when  not  in  the  iliac  fossa.  In  adults,  however,  this 
method  of  examination  is  chiefly  of  use  when  the  appendix  is  situated  in  the  pel- 
vis, when  on  bimanual  examination,  i.  e.,  with  one  hand  on  the  abdomen  and  a 
finger  of  the  other  hand  in  the  rectum,  it  is  sometimes  possible  to  outline  the 
swollen,  inflamed  appendix  or  a  peri-appendical  exudate. 

Percussion  . — Normal  tympany  should  be  present  throughout  the  abdo- 
men, with  more  or  less  modified  resonance  over  the  region  of  the  appendix  in 
the  presence  of  an  omental  tumor  or  a  greatly  distended  appendix,  or  when 
there  is  an  exudate.     Absolute  dulness,  if  present,  is  due  to  a  very  extensive 


Ill  HI  IGNOSIS. 

fibrinous  exudate,  or  to  an  abscess;  movable  dulness  in  the  flanks  indicates  the 
nee  of  effusion  into  the  general  peritoneal  cavity. 

A  u  s  c  u  1 1  a  t  i  <>  n  . — This  is  chiefly  of  use  in  determining  whether  symp- 
toms of  ileus  are  due  to  mechanical  obstruction  or  to  intestinal  paralysis. 

Urine  . — The  changes  in  the  urine  may  be  <>f  some  value  in  the  diagnosis 
of  a  few  obscure  cases  of  appendicitis,  especially  in  the  differentia]  diagnosis 
between  appendicitis  and  pn e  u  m  o  n  i  a  or  l  y  p h  o  i  d  f  e  v  e  r .  The  early 
appearance  of  indicanuria  and  the  relatively  later  appearance  of  albumen  are 
the  must  distinctive  features  (see  Chap.  XIX). 


DIFFERENTIAL  DIAGNOSIS. 

The  frequent  possibility  of  error  in  the  diagnosis  of  appendicitis  is  shown  by 
the  large  number  of  cases  collected  by  J.  M.  Spillissy  I  Ann.  Surg.,  IDOL',  vol.  35, 
]).  758)  illustrating  the  various  lesions  of  the  pelvis  and  abdomen  which  have 
been  mistaken  for  appendicitis.  The  most  important  sources  of  error  are  in  the 
acute  visceral  affections,  most  frequently  in  those  which  resull  in 
peritonitis.  There  are.  as  noted  by  Treves,  "certain  symptoms  common  to  all 
acute  disorders  within  the  abdomen  at  their  outset ,  in  which  a  sudden  and  violent 
impression  is  made  upon  the  great  nerve  centres.  These  symptoms  consist  of 
intense  and  sudden  pain  in  the  abdomen,  of  collapse  in  varying  degree,  and  of 
.•I  certain  amount  of  vomiting.  At  the  very  outset  such  conditions  as  peri- 
t  y  phli  t  is  ,  r  e  n  al  and  g  all-si  on  e  c  oli  c  ,  t  wis  tin  g  o  f  a  n 
ovarian  pedicle,  torsion  of  a  movable  kidney,  gen- 
eral peritonitis,  and  intestinal  obstruction,  have  been 
confused  one  with  another."  It  is  also  well  recognized  that  a  c  u  t  e  i  n  t  r  a  - 
t  h  o  r  a  c  i  c  a  f  f  e  c  t  i  o  n  s  ,  particularly  in  children,  may  in  the  beginning 
be  characterized  by  abdominal  symptoms  so  sudden  and  violent  that  the  disease 
itself  is  entirely  masked. 

Gastro-intestinal  Disease. — The  gastro-intestinal  diseases  liable  to  he  con- 
fused with  appendicitis  are  acute  gastritis  and  gastro-enter- 
i  t  i  s.  Appendicitis  is  frequently  mistaken  for  acute  indigestion,  hut  simple 
digestive  disturbances  are  seldom  mistaken  for  appendicitis.  Intestinal  colic, 
when  chiefly  affecting  the  appendical  region,  in  the  beginning  may  simulate 
appendicitis,  bul  is  distinguished  by  the  entire  absence  of  objective  signs.  In  the 
severer  forms  of  gastritis  the  attack  may  set  in  with  a  chill,  fever,  and  vomiting. 
There  may  he  constipation,  hut  very  often  there  is  diarrhea.  The  abdomen 
may  !»■  swollen  and  slightly  tender  in  the  epigastric  region.  In  the  acute  forms 
it  may  at  first  be  impossible  to  make  a  definite  diagnosis,  but  the  absence  of 
symptoms  referable  to  the  right  iliac  region  and  the  general  freedom  from 
tenderness  and  rigidity  are  sufficient  to  put  the  examiner  on  his  guard. 
Acute  enteritis  in  children  may  set  in  very  brusquely  with  vom- 
iting,  colicky   pain,    and    high    fever.     The    abdomen    is    sensitive    and     the 


DIFFERENTIAL    DIAGNOSIS.  415 

child  lies  with  its  legs  drawn  up.  The  frequency  of  this  affection  in 
young  children  and  the  characteristic  frequent,  offensive  stools  should 
prevent  error.  Acute  enteritis  accompanied  with  extension  of  the  inflam- 
mation to  the  peritoneal  surface  may  present  a  very  close  resemblance  to 
appendicitis.  A  case  related  by  Qubnu  and  Cavasse  (Bull.  et.  tucm.  de  la  Soc.  de 
chir.  deParis,  1900,  torn.  26,  p.  821)  is  that  of  a  boy,aged  seventeen,  who  suffered 
from  violent  abdominal  pain,  constant  vomiting,  and  obstinate  constipation. 
After  two  days  his  bowels  were  moved  with  enemata.  The  same  evening  there 
was  slight  abdominal  distention,  tenderness  and  rigidity  in  the  right  iliac  fossa, 
slight  fever,  and  a  hippocratic  fades.  A  diagnosis  of  appendicitis  was  made. 
Operation  revealed  a  normal  appendix,  but  the  small  intestines  were  congested 
and  covered  with  a  slight  exudate,  especially  over  the  lower  part  of  the  ileum. 

Stercoral  t  y  phi  i  t  is  is  now  recognized  as  a  rare  affection.  It  is, 
however,  occasionally  confused  with  appendicitis.  The  diagnosis  of  the  condi- 
tion is  fully  described  in  Chap.  XXI. 

Foreign  bodies  in  the  intestine,  especially  in  the  cecal 
region,  have  frequently  been  mistaken  for  appendicitis.  For  example,  in  a  case 
described  by  Mumford  (Boxt.  Med.  and  Surg.  Jour.,  1899,  p.  602)  a  girl,  aged  t  welve 
years,  was  suddenly  seized  with  severe  abdominal  pain  referred  to  the  umbilicus, 
followed  in  a  few  hours  by  vomiting.  Her  bowels  were  moved  with  castor 
oil,  but  the  pain  increased,  being  especially  severe  in  the  right  iliac  region.  On 
the  third  day  the  temperature  was  103°  F.  and  the  pulse  112.  Her  abdomen  was 
distended,  rigid,  and  tender,  especially  over  McBurney's  point.  Operation 
revealed  a  normal  appendix  and  the  cecum  distended  with  a  mass  of  orange 
pulp.  The  differential  diagnosis  in  such  cases  can  only  be  made  by  an  explor- 
atory  laparotomy. 

Perforation  of  gastro-intestinal  ulcers,  as  well  as 
large  perforations  of  the  appendix  in  which  there  is  an  extensive  extra- 
vasation of  septic  material,  are  all  accompanied  with  sudden  excruciating 
pain,  followed  almost  immediately  with  symptoms  of  shock.  In  all  of 
these  conditions  the  initial  pain  is  commonly  referred  to  the  umbilical 
or  epigastric  regions,  and  in  the  absence  of  a  history  pointing  to  gas- 
trie  or  intestinal  ulcer,  the  differential  diagnosis  is  often  impossible  without  an 
exploratory  operation.  In  perforative  appendicitis,  however,  there  is  usually 
a  predominance  of  tenderness  and  rigidity  in  the  right  iliac  region,  while  if  the 
pain  and  other  symptoms  continue  to  be  localized  in  the  epigastrium, 
perforated  gastric  ulcer  is  probable.  The  less  acute  forms  of  gastric 
ulcer,  where  adhesions  have  formed,  or  where  perforation  occurs  into 
the  lesser  abdominal  cavity,  are  not  apt  to  be  confused  with  appendicitis. 
A  further  aid  in  the  differential  diagnosis  is  the  greater  liability  of  young 
women  to  the  acute  forms  of  gastric  ulcer.  With  a  preceding  history  of 
gastric  disturbance,  especially  of  hematemesis  or  of  hemorrhage  from  the  bowel, 
the  diagnosis  of  gastric  or  duodenal  ulcer  is  seldom  doubtful.     The  possibility 


||i,  DIAGNOSIS. 

of  the  coexistence  of  the  two  affections,  as  in  the  cases  of  Treves  and  M  \thkson, 
already  cited,  should  be  borne  in  mind.  A  definite  diagnosis  of  intestinal  perfo- 
rations, especially  when  situated  in  t lu>  terminal  portion  of  the  ileum,  the  cecum, 
or  the  ascending  colon,  can  seldom  be  made  without  an  exploratory  incision. 
In  a  case  described  by  Deaver,  where  a  diagnosis  had  been  made  of  acute  appen- 
dicitis with  general  peritonitis,  there  was  a  perforation  of  the  ileum  about  1  \  or 
L'  in.  from  its  junction  with  the  cecum.  In  Quinard's  case  (cited  by  Spillissy) 
the  cecum  and  appendix  were  normal,  but  there  was  a  perforation  in  the  ileum 
30  cm.  from  the  ileocecal  junction. 

Ulceration  and  perforation  of  the  intestine  due  to  the  specific  inflammatory 
affections,  more  especially  typhoid  fever  ami  I  u  1>  e  r  c  u  1  o  s  i  s  , 
are  somewhat  frequently  confounded  with  appendicitis;  and,  on  the  other  hand, 
appendicitis  has  sometimes  been  mistaken  for  these  conditions.  The  clinical 
features  of  these  diseases  are  fully  considered  in  Chaps.  XXIX  and  XXXII. 

The  relation  of  mucous  colitis  and  appendicitis  is  interesting. 
As  I  have  said  elsewhere,  obstipation  ami  colitis  with  mucous  stools  are  often 
the  sign  of  a  latent  appendicitis,  and  are  cured  by  the  removal  of  the  appendix. 
The  differential  diagnosis,  as  a  rule,  rests  upon  the  history  of  mental  strain 
or  worry  preceding  the  onset  of  the  trouble  and  the  presence  of  marked  nervous 
manifestations,  such  as  hysteria,  hypochondriasis,  etc.  On  the  other  hand, 
a  history  of  a  preceding  acute  or  chronic  appendicitis  is  exceedingly  suggestive 
of  the  appendical  source  of  the  trouble.  In  any  case  of  mucous  colitis  in  which 
nervous  symptoms  are  not  a  predominant  feature  of  the  disease,  appendicitis 

should    lie   suspected. 

Tumors  in  the  ileocecal  region  or  in  the  ascending  colon  may  he 
mistaken  for  appendical  disease,  particularly  when  symptoms  of  perforative 
peritonitis  occur  in  a  person  who  had  not  previously  suffered  from  any 
distinct  evidence  of  the  disease.  The  exudate  accompanying  appendicitis, 
on  the  other  hand,  has  also  frequently  been  mistaken  for  a  true  neoplasm. 
Intestinal  tumors  may  progress  without  pain,  unless  the  parietal  peri- 
toneum is  involved,  and  in  the  absence  of  ulceration  there  may  he  hut 
slight  digestive  ami  constitutional  disturbances.  As  a  rule,  however,  there 
is  a  history  of  attacks  of  pain,  the  passage  of  blood  and  mucus  in  the 
stools,  loss  of  weight  and  of  strength.  In  late  cases  these  symptoms  are 
aggravated  and  there  may  he  more  or  less  cachexia.  Symptoms  of  chronic 
obstruction  are  frequently  observed.  There  may  be  slight  fever,  and  leueoey- 
tosis  is  usually  present.  A  tumor  can  generally  be  detected.  The  differentiation 
between  the  tumor  in  the  case  of  a  new  growth,  and  a  peri-appendical  exudate 
is  often  perplexing.  As  a  rule,  a  new  growth  is  more  or  less  freely  movable, 
is  sharply  circumscribed,  and  develops  gradually;  while  a  perityphlitic  infiam- 
matory  mass  is  less  movable,  less  definitely  outlined,  and  develops  rapidly,  usu- 
ally with  acute  local  and  constitutional  symptoms.  The  new  growth,  however, 
may  be  adherent  to  contiguous  structures  and  immovable;  while,  on  the  other 


DIFFERENTIAL    DIAGNOSIS.  117 

hand,  an  inflammatory  mass  may  possess  considerable  mobility.  Again,  the  nei  >- 
plasm  may  apparently  develop  suddenly  in  a  person  in  good  health,  whereas  the 
inflammatory  exudate  may  be  present  for  months  or  even  years,  as  in  Fengeb's 
case,  and  may  sometimes  be  accompanied  by  progressive  emaciation  and  cachexia. 
Two  years  ago  I  operated  upon  the  wife  of  a  physician  for  what  was  supposed  to  be 
chronic  appendicitis.  She  had  been  perfectly  well, except  for  some  trifling  indiges- 
tion, until  about  six  weeks  before  operation,  when  she  suffered  from  a  moderately 
severe  attack  of  pain  in  the  right  iliac  region  associated  with  some  fever,  accom- 
panied,  it  was  said,  by  a  leucocytosis  of  12,000.  She  was  ill  for  about  three  weeks, 
and  after  the  acute  symptoms  had  subsided  she  occasionally  felt  some  slight  pain 
in  the  right  side,  while  there  was  a  small,  definitely  circumscribed  mass  in  the 
iliac  fossa,  which  was  not  freely  movable,  and  was  not  very  sensitive.  There 
was  no  disturbance  of  digestion  and  the  bowels  were  normal.  Operation  revealed 
a  normal  appendix  and  a  carcinoma  of  the  cecum.  The  age  of  the  patient  is 
of  some  value  as  an  aid  to  the  diagnosis,  but  it  must  be  remembered  that  new 
growths  are  not  rare  in  youthful  persons  and  that  appendicitis  sometimes  occurs 
in  advanced  life. 

Lenzmann  states  that  the  distention  of  the  bowel  with  air  is  sometimes  an 
aid  in  differential  diagnosis.  In  the  case  of  carcinoma,  which,  in  the 
majority  of  cases,  is  an  annular  growth,  the  cecum  becomes  contracted  when  the 
intestine  is  distended  by  gas,  but  an  inflammatory  exudate  does  not,  as  a  rule, 
prevent  its  dilation.  This  procedure,  however,  is  not  always  trustworthy,  as  a 
new  growth  may  be  limited  to  the  posterior  surface,  and  would  not  then  interfere 
with  the  cecal  distention,  while,  on  the  other  hand,  extensive  adhesions  in  inflam- 
matory cases  may  greatly  limit  it.  A.  Gebsteb  (.V.  Y.  Med.  Jour.,  Aug.,  1902) 
had  a  case  of  relapsing  appendicitis  in  a  man,  twenty  years  old,  which  presented 
the  following  points  of  resemblance  to  a  neoplasm  of  the  ileocecal  region:  A 
large  rounded  tumor  of  gradual  development,  movable,  giving  very  little  pain 
when  the  patient  lay  quietly  in  bed,  and  not  accompanied  with  chills  nor  rise  of 
temperature,  the  bowels  being  regular.  The  chief  points  in  favor  of  the  inflam- 
matory nature  of  the  tumor  were  the  age  of  the  patient,  and,  especially,  the 
history  of  three  previous  attacks  of  appendicitis. 

Ileocecal  tumors  of  tubercular  origin  are  distinguished  from  malignant 
growths  on  the  one  hand,  and  simple  inflammation  on  the  other,  by  their  slow 
evolution,  their  characteristic  contour,  and,  especially,  by  the  history  of  ante- 
cedent tubercular  trouble,  or  the  presence  of  enlarged,  hard  glands  in  the  cervi- 
cal or  other  region. 

Acute  intestinal  o  b  s  t  r  u  c  t  i  0  n  may  be  due  to  stran- 
gulation, volvulus,  intussusception,  strictures,  or 
f  o  r  e  i  g  n  bodies.  In  all  of  these  conditions  the  symptoms  are  sim- 
ilar to  acute  appendicitis,  and  all  have  been  confused  with  it.  If  the  case  is 
seen  early  there  is,  in  the  majority  of  cases,  no  difficulty  in  the  differential  diag- 
nosis, the  acute  onset  with  severe  abdominal  pain,  becoming  more  intense  and 
27 


lis  DIAGNOSIS. 

continuous  and  soon  followed  by  vomiting  of,  .-it  first,  the  contents  of  the  stomach, 
then  bile,  and  then  fecal  matter,  being  very  characteristic.  The  presence  of 
obstipation  and  early  collapse  are  also  most  important  diagnostic  features.  The 
absence  of  fever  at  the  onset,  and  of  early  high  leucocytosis,  as  well  as  the  absence 
of  early  abdominal  tenderness,  distinguish  it  from  appendicitis.  Later  on, 
when  symptoms  of  peritonitis  develop,  the  differential  diagnosis  may  be  impos- 
sible, unless  a  clear  history  of  the  onset  of  the  attack  can  be  obtained.  Stran- 
gulation of  the  intestine  by  bands  of  adhesions,  by  a  Meckel's  diverticulum,  by 
the  adherent  appendix,  or  by  its  incarceration  in  peritoneal  pockets,  is  most  com- 
monly mistaken  for  appendicitis.  Spillissk  ha-  collected  Is  cases  of  obstruc- 
tion due  tn  trouble  involving  .Meckel's  diverticulum,  in  which  a  diagnosis  of 
appendicitis  was  made.  Diseases  of  this  rudimentary  structure  cannot  be 
distinguished  from  appendicitis  before  operation  (see  Chap.  XXV). 

Incarcerated  internal  hernia  may  readily  l>e  confused 
with  appendicitis,  particularly  when  the  incarceration  is  not  complete.  As  a 
rule,  however,  there  are  early  sijrns  of  complete  obstruction,  while  symptoms 
of  ileus  in  appendicitis  are  not  presenl  in  the  beginning  of  general  peritonitis, 
but  follow  its  development.  J.  B.  DEAVER  observes  that  incipient 
hernia  may  simulate  chronic  appendicitis.  Palpation  of  the  inguinal 
rings  will  usually  reveal  the  source  of  the  trouble  in  such  cases. 

In!  ussuscept  ion  may  present  a  close  resemblance  to  acute  appen- 
dicitis. In  both  there  may  be  the  initial,  severe,  colicky  pain,  vomiting,  and 
collapse.  The  pain  may  be  confined  to  the  right  side  and  a  tumor  may  be  felt.  In 
intussusception  the  pain  resembles  a  severe  colic  and  is  often  relieved  by  pres- 
sure; vomiting  is  more  marked,  and  there  is  severe  tenesmus  with  escape  of 
blood,  or  of  blood  and  mucus  from  the  bowels.  The  tumor  is  better  defined, 
less  tender,  and  movable.  In  every  case  of  acute  colic  ill  young  children  the 
question  of  intussusception  should  be  considered  and  the  examination  directed 
to  its  possible  discovery.     Examples  of  this  condition  are  given  in  Chap.  XX. 

Intestinal  parasites  may,  in  children,  give  rise  to  abdominal 
symptoms,  which  in  their  brusque  onset  and  violent  character,  together  with 
the  consequent  severe  constitutional  disturbances,  closely  simulate  acute  appen- 
dicitis. Instructive  examples  of  this  confusion,  given  by  C.  Akbor£-Rally 
and  Metchnikopp,  are  described  in  Chap.  XX.  The  differential  diag- 
nosis rests  chiefly  upon  the  discovery  of  the  ova  of  the  parasites  in  the 
stools.  It  must  be  borne  in  mind,  however,  as  is  clearly  shown  in  Chap. 
XX,  that  intestinal  parasites  may  be  associated  with,  and  indeed  may  lie  the 
exciting  cause  of,  acute  appendiceal  inflammation.  The  blood  examination 
may  be  of  great  value  in  doubtful  cases,  as  in  helminthiasis  a  high  grade  of 
eosinophiles  is  frequently  found,  while  in  the  early  stages  of  acute  appendicitis 
there  is  often  a    marked  diminution  or  a  total   absence  of   these  cells   (SlMON, 

ical  Diagnosis).     As  the  infection  terminates,  however,  the  eosinophiles  are 
relatively  and  actually  increased   ( David.  Thkse  de  Paris,  1903). 


DIFFERENTIAL    DIAGNOSIS.  419 

Lead  Colic. — In  the  absence  of  general  symptoms  of  plumbism,  lead  colic 
may  be  mistaken  for  appendicitis,  and  vice  versa.  Bernard  (These  de  Paris, 
1901)  refers  to  a  case  in  which  the  appendix  was  removed  on  account  of  abdom- 
inal  symptoms   suggestive   of   appendicitis.     The   following  year   the   patient 

Buffered  from  an  attack  of  an  exactly  similar  nature,  and  it  was  then  found  that  he 
was  the  subject  of  lead  colic.  An  attack  of  colic  in  chronic  lead  poisoning  is 
often  preceded  by  gastric  or  intestinal  symptom-,  particularly  constipation.  The 
pain  is  over  the  whole  abdomen  and  is  usually  paroxysmal.  There  is  often,  in 
addition,  a  dull  heavy  pain  between  the  paroxysms,  and  there  may  be  vomiting; 
attacks  of  pain  with  acute  diarrhea  may  also  occur.  Acute  lead  poisoning  may 
present  vomiting  and  pain  in  the  abdomen,  with  gastro-intestinal  symptoms  of 
the  most  intense  description,  accompanied  by  collapse  which  may  prove  rapidly 
fatal.  In  lead  colic,  unlike  colic  due  to  inflammatory  disease,  there  is  an  absence 
of  general  or  localized  tenderness,  in  fact,  the  pain  is  usually  relieved  by  pressure. 
The  pulse-rate  instead  of  being  accelerated  is  retarded,  and  there  is  increased 
tension  (Ritzel  cpioted  by  (  teler).  The  Mood  examination  is  here  of  importance 
in  the  differential  diagnosis.  According  to  Da  Costa  (Clinical  Hematology,  1001), 
there  is  often  pronounced  leucocytosis,  especially  in  cases  with  acutely  toxic 
symptoms,  but  granular  basophilia  of  the  erythrocytes  can  be  detected  even 
in  the  earliest  stage  of  plumbism,  while  in  appendicitis  this  does  not  occur.  Acute 
poisoning  may  simulate  acute  appendicitis,  which  at  the  outset  presents  signs 
of  acute  diffuse  peritonitis  accompanied  by  signs  of  collapse.  In  such  a  case 
the  temperature,  the  pulse,  and  the  leucocyte  count  may  not  present  points  of 
differentiation.  As  acute  lead  poisoning  is  usually  the  result  of  a  large  amount 
of  poison  taken  accidentally  or  with  suicidal  intent,  the  history  will  usually  give 
the  clue.  The  most  important  cases  are  those  in  which  there  is  coincident  plumb- 
ism and  appendicitis.  A  patient  presenting  general  symptoms  of  lead  poisoning 
may  be  seized  with  an  attack  of  acute  or  chronic  appendicitis,  which  is  considered 
to  be  merely  the  usual  abdominal  symptoms  of  plumbism.  The  chief  points  in  the 
differential  diagnosis  are  the  localization  of  the  pain  in  the  right  iliac  fos<a. 
the  presence  of  diffuse  or  localized  tenderness,  ami  rigidity  of  the  abdominal 
walls.  The  temperature  is  more  or  less  elevated  and  the  pulse  accelerated.  Leu- 
cocytosis, if  present,  is  a  valuable  confirmatory  sign  The  detection  of  a  mass 
in  the  right  iliac  fossa  is,  of  course,  positive  evidence  that  the  attack  is  not  due  to 
plumbism. 

Affections  of  the  Peritoneum  and  Mesentery. — Tubercular  peritonitis, 
both  in  the  chronic  and  the  acute  form,  may  simulate  appendicitis.  Many 
cases  set  in  acutely  with  fever,  abdominal  tenderness,  and  the  usual  symptoms 
of  an  ordinary  acute  peritonitis,  the  predominating  symptoms  often  being  referred 
to  the  right  iliac  region.  These  cases  are  frequently  mistaken  for  appendicitis 
with  localized  peritonitis.  In  other  instances  the  onset  is  exceedingly  brusque, 
with  acute  abdominal  symptoms  and  marked  constitutional  disturbance,  sim- 
ulating acute  perforative  appendicitis  with  generalized  peritonitis.     A  case  de- 


420  DIAGNOSIS. 

scribed  bj  Rousseau  l  These  de  Paris,  L901)  is  thai  of  a  child  who  awakened  with 
sudden  sharp  pain  in  the  abdomen,  the  maximum  intensity  of  the  pain  being  in 
the  right  Hank.  She  vomited  almost  immediately,  and  at  the  same  time  several 
ascarides  were  passed  per  rectum.     A  few  hours  later  she  vomited  some  mucus. 

Twelve    hours   after    the   onset    of   the   atlaek  she  was  admitted   to  the   hospital 

in  a  critical  condition,  presenting  the  typical  fades  abdominalis,  cold  extremities, 
rapid   respiration,  ami  extremely  small  pulse.    The  abdomen  was  distended, 

ami  palpation  in  the  righl  Hank  elicited  acute  pain  ami  muscular  resistance. 
A  diagnosis  was  made  of  probable  peritonitis  clue  to  perforative  appendicitis, 
and  immediate  operation  performed.  There  was  a  small  amount  of  serous 
fluid  in  the  abdominal  cavity  ami  the  serous  membrane  was  covered  with  line 
tubercular  granulations.  The  child  did  not  improve  after  the  operation,  bul 
presented  signs  of  increasing  intoxication,  and  died  on  the  sixth  day.  An  instance 
of  the  chronic  form,  given  by  TREVES,  is  the  case  of  a  boy,  aged  thirteen,  admitted 
to  the  hospital  complaining  of  pain  in  the  right  side  and  occasional  vomiting. 
He  declared  that  the  pain  began  suddenly  some  months  previously,  being  accom- 
panied with  vomiting  and  a  tender  swelling  in  the  cecal  region,  which  had  not 
entirely  disappeared.  An  exploratory  incision  revealed  a  localized  tubercular 
peritonitis,  with  evidence  of  extension  over  the  general  serous  surfaces.  The 
appendix  appeared  normal.  The  most  characteristic  features  of  the  acute  attack 
are  I  he  more  moderate  fever,  the  less  acute  abdominal  tenderness,  the  more  indef- 
inite localization  of  the  symptoms,  the  more  frequent  occurrence  of  fecal 
vomiting.  None  of  these  indications,  however,  are  distinctive,  ami  in  some 
instances  the  differential  diagnosis  is  impossible.  Most  important  among  the 
diagnostic  points  are  the  personal  and  hereditary  antecedents  of  the  patient. 

Genera]  peritonitis  secondary  to  measles  has  been 
described  by  R.  T.  Mourns  (X.  )'.  Med.  .lour..  1899,  vol.  1,  p. 470) as  being  mis- 
taken for  acute  appendicitis  with  general  peritonitis. 
I  Iperation  showed  the  peritoneum  thickened  and  infiltrated,  while  the  abdominal 
cavity  was  filled  with  viscid  lymph.  Recovery  was  retarded  by  an  attack  of 
meningitis  accompanied  by  pleurisy  and  pericarditis. 

A  case  of  lipoma  of  the  ni  e  s  e  n  t  e  r  v  ,  twisted  on  its  axis  and 
producing  gangrene  and  perforation  of  the  ileum,  which  were  at  first  mistaken 
for  acute  perforative  appendicitis,  has  been  sent  me  by  A.  C.  Bernays  of  St. 
Louis.  The  patient,  a  girl  six  years  old,  was  suddenly  taken  with  severe  colic 
followed  by  vomiting.  There  was  an  obvious  tumor  in  the  iliac  fossa,  hut  little 
tenderness.  The  child  was  moribund  when  sent  to  the  hospital,  bul  was 
operated  on  as  a  last  resort — too  late,  however,  to  save  her  life. 

A  mass  of  gangrenous  omentum,  causing  acute  abdominal 
symptoms,  associated  with  shock,  in  a  case  reported  by  SpiLLISSY,  was  oper- 
ated on  for  supposed  appendicitis. 

E  n  1  a  r  g  e  d  r  e  t  r  o  c  e  <•  a  1  a  n  d  ret  r  o  c  o  1  i  c  si  a  n  d  s  have 
frequently  given  rise  to  a  diagnosis  of  appendicitis.     The  majority  of  these  cases 


DIFFERENTIAL    DIAGNOSIS.  421 

have  been  due  to  tubercular  disease,  but  in  a  case  reported  by  Condamm  and 
Vorox  (cited  by  Spillissy)  the  adenitis  was  of  syphilitic  origin.  A  unique 
case  of  typhoidal  adenitis  mistaken  for  appendicitis  has  been  described  by 
Richardson  (N.  Y.  Stale  Med.  Jour.,  July,  1901  j.  Russell  (Mod.  Med.  Sci., 
Feb.,  1902)  reports  a  case  of  fatal  v  a  c  c  in  a  t  i  o  n  i  n  f  e  c  t  i  o  n  which 
presented  symptoms  resembling  acute  appendicitis.  The  vaccination,  on  the 
right  thigh,  had  apparently  been  followed  by  suppurative  adenitis  of  the 
inguinal  and  iliac  glands  and  diffuse  fibro-purulent  peritonitis. 

Diseases  of  the  Kidneys  and  Ureters. — Floating  kidney  has  frequently 
been  mistaken  for  appendicitis,  and  several  instances  have  been  recorded  in 
which  the  true  condition  was  only  discovered  at  operation.  In  a  case  described 
by  .Miller  (Med.  flee,  1900,  p.  353)  the  presence  of  a  mass  in  the  right  iliac  fossa 
with  a  history  of  more  or  less  constant  pain  extending  over  about  a  year,  was 
very  suggestive  of  appendical  trouble.  The  occurrence  of  acute  attacks  ("  Diet  I 's 
crises"')  characterized  by  severe  abdominal  pain,  chills,  nausea,  vomiting,  fever, 
and  collapse  in  a  patient  who  is  not  known  to  be  suffering  from  floating  kidney, 
may  be  very  misleading.  The  kidney  during  these  attacks  is  swollen,  tender, 
and  often  less  freely  movable,  while  on  account  of  the  localized  tenderness  and 
the  rigidity  of  the  abdominal  walls  palpation  may  be  difficult  and  unsatisfac- 
tory. The  chief  diagnostic  features  are  the  characteristic  shape  of  the  organ 
together  with  its  mobility,  and  in  the  ordinary  cases  the  diagnosis  is  rarely  doubt- 
ful. By  making  the  patient  relax  thoroughly,  especially  when  lying  on  the  left 
side  with  the  right  thigh  flexed,  the  kidney  can  lie  readily  grasped  and  made 
to  slip  back  into  its  normal  position.  .Sometimes  also  a  depression  in  the  flank 
corresponding  to  the  normal  site  of  the  kidney  is  plainly  visible. 

During  the  acute  attacks  the  muscular  rigidity  is  usually  more  diffuse  and 
not  so  marked  as  in  appendicitis,  and  the  tenderness  is  often  more  severe  poste- 
riorly. The  condition  of  the  urine  is  sometimes  an  aid  in  the  differential  diagnosis. 
During  acute  renal  attacks  an  excess  of  uric  acid  is  common,  but  high-colored, 
scanty  urine,  and  the  occasional  presence  of  pus  and  blood  may  accompany 
either  affection.  Acute  anuria  may  also  occur  in  either,  but  with  the  subsequent 
voiding  of  a  large  amount  of  urine  the  renal  pain  is  entirely  relieved,  while 
appendical  symptoms  are  not  affected.  A  diagnostic  point  of  great  significance 
is  the  frequent  occurrence  of  floating  kidney  in  neurasthenic  women.  A  history 
of  attacks  of  pain  not  always  referred  to  the  same  region,  or  a  history 
of  intermittent  hydronephrosis,  indicate  a  movable  kidney.  Finally,  in  all 
doubful  cases,  examination  under  ether  narcosis  will  at  once  reveal  the  presence  of 
a  floating  kidney.  It  is,  however,  of  great  importance  to  remember  that  the  two 
affections  frequently  coexist,  some  observers  believing  that  a  large  percentage  of 
cases  of  chronic  appendicitis  is  a  constant  accompaniment  of  right  floating  kid- 
ney. It  is  therefore  essential  in  the  presence  of  a  floating  kidney  to  definitely 
exclude  the  presence  of  appendicitis. 

Renal  calculus  may  produce  symptoms  closely  simulating  acute  or  chronic 


122  DIAGNOSIS. 

appendicitis.  Renal  colic  due  to  the  entrance  of  a  calculus  into  the  ureter  may 
sel  in  abruptly  without  apparent  cause,  or  may  follow  a  strain  in  lifting,  ll  is 
described  by  Osler  as  characterized  bj  agonizing  pain,  which  starts  in  the  flank 
of  the  affected  side,  passes  down  the  ureter,  and  is  fell  in  the  testicle  and  the  inner 
side  of  the  thigh.  The  pain  may  also  radiate  through  the  abdomen  and  chest  and 
he  very  intense  in  the  back.  In  severe  attacks  there  are  nausea  and  vomiting 
and  the  patient  is  collapsed.  A  chill  may  precede  the  outbreak,  and  the 
temperature  may  rise  as  high  as  103°  I.  Perspiration  breaks  out  upon  the  lace 
and  the  pulse  is  feeble  and  quick.  Micturition  is  frequent,  and  occasionally  pain- 
ful, while  the  urine,  as  a  rule,  is  bloody.  The  attack  may  not  last  longer  than 
an  hour;  in  other  instances  it  continues  for  a  day  or  mure,  with  periods  of 
temporary  relief.  There  is  usually  tenderness  on  the  affected  side.  If  the  cal- 
culus remains  in  the  kidney  there  is  usually  a  dull  pain,  often  referred  to  the  hack. 
In  s.uiic  cases  the  pain  comes  on  in  acute  paroxysms.  Hematuria  is  common, 
hut  by  no  means  constant,  and  the  urine  may  he  clear  for  days.  There  may 
also  he  intermittent  attacks  of  pyuria.  The  distinctive  features  in  the  differ- 
ential diagnosis  are  the  situation  and  direction  of  the  pain,  the  retracted  and 
painful  test  icle,  and  the  chanties  in  the  urine.  When  the  calculus  is  in  the  lower 
portion  of  the  ureter,  just  above  the  pelvic  brim,  and  the  pain  and  tenderness 
ci 'iii re  at  this  point,  the  diagnosis  is  sometimes  exceedingly  difficult.  The  X-ray 
examination  is  a  most  valuable  diagnostic  aid,  hut  may  lead  to  erroneous  con- 
clusions, particularly  when  a  ureteral  calculus  is  found  in  the  iliac  fossa. 

The  following  interesting  examples  of  the  confusion  that  may  exist  between 
these  conditions  have  been  sent  me  by  Prof.  D.  Giordano  of  Venice,  Italy: 

I.  A  hoy,  Hire  thirteen,  had  a  history  of  three  previous  attacks  of  sudden  acute 
pain  in  the  right  ilio-inguinal  region,  in  which  a  diagnosis  was  made  of  muscular 
rheumatism.  A  fourth  attack  began  with  pain  all  over  the  right  side  and  radiat- 
ing to  the  crural  region,  accompanied  with  severe  strangury  and  diffi- 
cult, frequent,  and  painful  micturition.  A  diagnosis  of  renal  calculus  was  made. 
Mr.  Giordano  was  then  called  in  to  examine  the  bladder.  The  vesical  examina- 
tion was  negative  and  the  urine  normal,  save  for  the  abundance  of  urates.  There 
was.  however,  tenderness  on  pressure  over  McBurney's  point,  and  Dr.  Giordano 
made  a  diagnosis  of  appendicitis  with  reflex  strangury.  At  the  end  of  a  month 
there  was  almost  no  amelioration  and  micturition  continued  frequent  and  difficult. 
Laparotomy  then  performed  showed  the  appendix,  erect  and  trumpet-shaped, 
richly  vascular,  hut  free  from  adhesions.  lis  removal  was  followed  by  complete 
relief  of  the  urinary  difficulty. 

II.  The  patient  was  a  woman,  twenty-seven  years  old,  whose  trouble  had 
begun  six  years  previously,  on  the  eighth  day  after  labor,  with  pain  in  the 
right  lumbar  and  hypogastric  regions.  The  pain,  which  was  constant,  was  marked 
by  a  c  u  t  e  a  t  t  a  c  k  s  of  st  r  a  n  g  u  r  y  .  After  three  years  of  suffering, 
double  oophorectomy  was  performed,  without  benefit.    The  pain  continued  and  was 

d    with    alternate    constipation    and    diarrhea.     A    month    before  consult- 
ing  l'r.   Giordano   the   pain   became  more   violent,  and  was   localized  in  the  iliac 


DIFFERENTIAL    DIAGNOSIS.  423 

fossa,  although  radiating  throughout  the  entire  abdomen.  There  was  mucus  in 
the  stools,  frequent  rigidity,  and  occasional  vomiting.  The  abdomen  was  dis- 
tended, tender  on  pressure  in  the  right  iliae  region,  and  acutely  tender  over  Mc- 
Burney's  point.  There  was  a  small  painful  tumor  at  the  base  of  the  right  broad 
ligament.  The  urine  contained  a  large  amount  of  indican,  no  albumen,  and  no 
biliary  pigments.  Operation  revealed  a  long,  hyperemic,  claviform  appendix,  and 
the  tumor  noted  at  the  base  of  the  broad  ligament,  which  had  been  taken  for  an 
inflamed  lymphatic  gland,  proved  to  lie  a  ureteral  calculus  2  cm.  long  and  1.5  cm. 
in  its  greatest  diameter. 

Another  case,  sent  me  by  A.  J.  Ochsner  of  Chicago  (personal  communication  \, 

is  as  follows : 

A  man,  fifty-five  years  old.  gave  a  history  of  several  acute  attacks  of  appen- 
dicitis extending  over  a  period  of  two  and  one-half  years.  In  one  attack  there 
was  severe  pain  in  the  region  of  the  bladder,  accompanied  with  frequent,  painful 
micturition,  and  at  this  time  a  few  clots  of  blood  were  passed  in  the  urine.  Four 
weeks  before  admission  to  the  hospital  the  patient  suffered  from  a  severe  attack 
of  pain  in  the  abdomen  which  became  more  marked  in  the  right  iliac  region  on 
the  second  day,  but  changed  to  the  left  iliac  region  on  the  third,  and  then  extended 
to  the  left  kidney.  There  was  severe  nausea,  constipation,  and  slight  fever,  the 
whole  attack  lasting  one  week.  On  admission,  three  weeks  later,  the  patient  had 
a  good  appetite;  the  temperature  and  pulse  were  normal.  There  was  slight  ten- 
derness at  McBurney's  point,  but  apart  from  this  the  abdominal  examination  was 
negative.  Urinalysis  was  also  negative.  A  skiagram  showed  two  very  definite 
shadows,  considered  to  be  calculi  in  the  left  ureter.  On  account  of  the  obscure 
history,  a  median  incision  was  made.  The  small  intestines  were  found  acutely 
congested,  the  appendix  was  adherent  to  the  inner  side  of  the  cecum,  and  surrounded 
by  omentum,  which  inclosed  a  large  perforation  in  the  vermiform  appendix.  There 
were  enlarged  glands  in  the  mesappendix,  and  in  the  mesentery  of  the  ileum  to  the 
left  of  the  median  line  were  two  calcareous  bodies. 

Brewer  (Ann.  Surg.,  1001,  vol.  33,  p.  590)  refers  to  three  cases  in  which 
a  diagnosis  was  made  of  appendicitis,  but  which  proved  to  be  ure- 
t  e r  a  1   and    renal   calculi. 

Pyonephrosis    may    closely    resemble    acute   or    chronic    relapsing 

appendicitis.  C.  P.  Noble  (personal  communication)  had  a  case  in  which  the 
patient  was  operated  on  for  supposed  appendicitis,  but  the  appendix  was  found 
to  be  normal,  and  a  pyelitis  the  source  of  the  trouble.  The  patient  got  well 
of  the  pyelitis,  while  in  bed  recovering  from  the  operation.  The  most  distinctive 
features  are  the  changes  in  the  urine  accompanying  the  acute  attacks  of  pain, 
and  the  rigors,  high  fever,  and  sweats  indicating  a  pyemic  condition.  The  position 
of  the  tenderness  and  the  distinctly  outlined  tumor  in  the  kidney  region  usually 
lead  to  a  correct  diagnosis.  The  presence  of  cystitis  is  a  confirmatory  sign, 
of  value  in  some  cases.  The  fact  that  the  renal  or  ureteral  suppuration  may 
lie  secondary  to  appendieal  disease,  as  in  the  cases  described  on  page  204,  and  in 


|_'|  DIAGNOSIS. 

Lenzmann's  and  in  Treves'  cases,  should  be  borne  in  mind.  In  chronic  cases 
of  persistenl  pain  in  the  right  side  where  a  definite  diagnosis  cannol  be  made, 
I  have  found  the  following  procedure  of  value  in  excluding  renal  disease:  With 
the  patienl  in  the  knee-chest  posture  a  cystoseope  is  introduced,  and  through  it  a 
suitable  catheter  is  passed  into  the  ureter  and  up  to  the  kidney.  The  pelvis 
n!'  the  kidney  is  then  distended  with  sterilized  water,  and  as  soon  as  its  norma] 
capacity  (shown  by  the  measured  resistance)  is  exceeded  there  is  more  or  less 
severe  pain.  It  this  pain  is  similar  to  the  pain  from  which  the  patienl  has  suffered, 
there  is  fairly  conclusive  evidence  that  the  kidney  is  at  fault,  ami  vice  versa. 

Per  i  n  e  phr  i  t  i  c  Abscess.  As  suppurative  peri-appendicitis  fre- 
quently involves  the  perirenal  tissue  and  is  one  oi  the  common  causes  of  peri 
nephritic  abscess,  the  differential  diagnosis  depends  chiefly  upon  the  history  of 
the  events  leading  up  to  the  attack.  If  the  onset  is  ma  iked  by  the  usual  symp- 
toms of  appendicitis,  the  diagnosis  is  clear;  while  with  a  history  of  injury  to 
the  lumbar  region  or  of  a  preexisting  kidney  affection,  followed  by  the  sudden 
or  the  insidious  development  of  the  ahscess,  there  is  usually  no  difficulty  in  deter- 
mining the  origin  of  t  lie  disease.  Si'it.t.issv  refers  to  a  case  in  which  a  gonorrhea] 
ureteritis,  secondary  to  a  prostatitis,  simulated  acute  appendicitis. 

i;  i' n  a  1  tumors  are  rarely  mistaken  for  appendicitis,  hut  when  the 
appendix  ascends  toward  the  lower  pole  of  the  kidney,  an  exudate  may  form 
in  this  region  and  present  all  the  characteristics  of  a  renal  tumor.  The  chief 
features  upon  which  the  diagnosis  rests  are:  The  gradual,  insidious  development 
of  the  tumor,  its  progressive  growth,  the  slow  onset  and  increase  of  pain, 
its  steady  character,  and  the  fad  of  its  being  located  chiefly  in  the  loin.  The 
urinary  changes  are  of  great  importance,  especially  the  occurrence  of  hema- 
turia, which  is  a  fairly  constant  accompaniment  of  renal  tumors,  hut  is 
comparatively  rare  in  appendical  disease,  and  even  if  present  is  very  seldom 
persistent.  An  example  of  a  renal  tumor  mistaken  for  appendicitis  is  given 
by  \V.  II.  Harsha  (Ann.  Surg.,  March,  1902),  in  which  a  man,  forty 
years  of  age,  had  for  some  time  presented  the  usual  evidences  of  a  large 
appendical  abscess,  which  finally  ruptured,  producing  a  consequent  general 
peritonitis.  On  making  an  incision  over  the  site  of  the  appendix,  a  solid  mass 
was  encountered,  which  proved  to  he  a  large  tumor  of  the  kidney  containing  an 
abscesswhich  had  ruptured  into  the  peritoneal  cavity.  Microscopic  examina- 
tion showed  that  the  tumor  was  a  fibro-sarcoma. 

Diseases  of  the  Gall-bladder. — livery  surgeon  of  wide  experience  has  had 
cases  in  which  it  was  exceedingly  difficult,  and  often  impossible  without  an 
exploratory  section,  to  differentiate  between  appendicitis  and  acute  or  chronic 
diseases  of  the  gall-bladder  and  its  ducts.  Acute  cholecystitis  sets 
in  with  severe  paroxysmal  pain,  situated  most  commonly  in  the  right  side  of 
the  abdomen,  or  in  the  region  of  the  liver,  hut  frequently  in  the  epigastrium  and 
sometimes  in  the  ileocecal  region;  "nausea,  vomiting,  rise  of  temperature  and 
pulse,  abdominal  distention,  rigidity,  general  tenderness  becoming  localized. 


DIFFERENTIAL    DIAGNOSIS.  425 

quickly  follow."  Intestinal  obstruction  is  often  a  prominent  symptom.  The 
symptoms  may  not  be  definitely  localized  in  inflammation  of  the  gall-bladder ; 

while,  on  the  other  hand,  if  the  appendix  is  in  a  high  retro-colic  position,  the 
maximum  intensity  of  the  pain  and  tenderness  may  be  referred  to  the  hypo- 
chondriac region.  With  a  history  of  previous  attacks  of  cholecystitis,  or  if  the 
attack  occurs  during  convalescence  from  typhoid  fever,  cholecystitis  may  be 
suspected. 

Empyema  of  the  gall-bladder,  in  addition  to  the  symp- 
toms of  cholecystitis,  presents  a  definite  tumor  in  the  right  side,  which  may  in- 
crease the  diagnostic  difficulties.  Osler  records  the  case  of  a  woman,  admitted 
to  the  hospital  with  a  history  of  very  sudden  onset  of  severe  pain,  three  days  pre- 
viously, in  the  right  side  of  the  abdomen,  and  with  an  ill-defined  tumor  mass  low 
down  in  the  right  Hank.  She  was  transferred  at  once  to  the  surgical  side  for  opera- 
tion for  supposed  appendicitis,  when  the  condition  proved  to  he  an  acutely  dis- 
tended and  inflamed  gall-bladder,  almost  on  the  point  of  perforating.  The  tumor 
in  appendical  inflammation  can  usually  be  distinguished  by  the  presence  of  a 
tympanitic  zone  between  the  lower  border  of  the  liver  and  the  mass,  while  the 
distended  gall-bladder  disappears  under  the  liver  and  the  dulness  over  the 
mass  merges  into  the  liver  dulness.  In  gall-bladder  inflammation  there  is 
almost  invariably  a  tender  spot  a  little  above  and  to  the  right  of  the  umbilicus. 

Hepatic  colic,  due  to  the  entrance  of  gall-stones  into  the  cystic 
or  common  duct,  may  present  many  points  of  resemblance  to  acute  appendicitis. 
The  attack  sets  in  suddenly  with  agonizing  pain,  often  associated  with  rigor, 
fever,  and  abdominal  rigidity.  The  pain,  as  a  rule,  is  located  in  the  right  hypo- 
chondrium  and  the  epigastrium  radiating  toward  the  scapula,  while  in  appen- 
dicitis the  pain  usually  extends  toward  the  umbilicus  and  downward.  Tenderness 
under  the  costal  margin  is  characteristic  of  inflammation  of  the  gall-bladder  and 
its  ducts.  In  hepatic  colic  an  initial  rigor  is  more  frequent,  the  pain  is  more 
intense,  and  the  nausea  and  vomiting  more  continuous  from  the  first.  Sonnen- 
BTJRG  enumerates  as  the  most  distinctive  features  of  gall-bladder  inflamma- 
tion and  biliary  calculus:  the  high  position  of  the  exudate;  the  slight  constitu- 
tional disturbance;  the  direction  of  the  dulness  on  percussion,  especially  its 
passing  into  the  liver  dulness.  Icterus  may  occur  or  may  be  absent  in 
either  case. 

Rupture  of  the  gall-bladder  occurring  suddenly  without 
previous  evidence  of  any  disease  of  the  gall-bladder  has  been  mistaken  for  acute 
perforative  appendicitis.  Several  examples  of  this  mistake  are  recorded.  (!.  M. 
Pond  (Med.  Rec,  April,  1898,  p.  585)  relates  the  case  of  a  man.  forty-five  years 
of  age,  who.  while  lifting  a  heavy  weight,  was  seized  with  severe  epigastric 
pain,  and  collapse.  A  diagnosis  of  appendicitis  was  made.  The  next  day  he 
had  but  a  slight  rise  of  temperature;  his  pulse  was  120;  his  face  anxious;  the 
pain  was  localized  over  McBurncy's  point  and  the  tenderness  well  marked.  The 
right  rectus  muscle  was  rigid.     When  the  abdomen  was  opened  a  quart  or 


426  M  ^.GNOSIS. 

more  of  bile  gushed  out,  and  the  attack  was  found  to  be  due  to  rupture  of  the 
enlarged,  distended  gall-bladder.  E.  G.  Field  of  Norfolk,  Va.  (personal  com- 
munication I,  saw  a  case  of  nipt urc  of  the  common  duel  \\  bich  closely  simulated 
acute  perforative  appendicitis.     A  physician,  aged  fifty-two  years,  was  attacked 

witli  sudden  severe  pain  in  the  right  side  of  the  abdomen,  extending  from  the 
region  of  the  liver  to  the  groin.  There  was  great  tenderness  unci-  this  region 
ami  the  right  rectus  muscle  was  tense.  There  was  considerable  meteorism 
which  gradually  increased  until  the  respirations  were  greatly  interfered  with. 
The  temperature  was  subnormal,  the  pulse  small  and  weak.  The  patient  died 
about  thirty-six  hours  after  the  onset  of  the  attack,  in  great  agony.  Autopsy 
showed  rupture  of  the  common  duct  with  beginning  general  peritonitis. 

In  considering  the  question  of  the  differential  diagnosis  between  appendicitis 
and  diseases  of  the  liver  and  gall-bladder  the  surgeon  has  not  simply  to  determine 
whether  he  is  dealing  with  a  case  of  appendicitis  or  of  hepatic  or  gall-bladder 
disease;  he  has  also  to  consider  that  important  group  of  cases  in  which  affec- 
tions of  the  organs  coexist,  particularly  the  cases  in  which  the  disease  of  the 
liver  and  gall-bladder  is  secondary  to  the  appendical  inflammation.  In  the  pre- 
ceding sections  the  frequency  .if  these  complications  has  been  emphasized, 
and  attention  has  been  called  to  the  fact  that  pylephlebitis  and  liver  abscesses 
may  he  the  result   of  an  unsuspected  subacute  appendicitis.     The  diagnosis 

of  the  secondary  condition  in  these  cases  is  easy,  hut  the  primary  affection  is 
often  completely  masked.  1  have  met  with  two  or  three  instances  in  which  the 
persistent  pain  in  the  right  hypochondrium,  associated  with  jaundice,  led  to  a 
diagnosis  of  cholelithiasis  or  cholangitis,  and  at  operation  a  chronic  appendicitis 
was  found,  with  adhesions  involving  the  gall-bladder  ami  compressing  the  ducts. 
Not  infrequently  gall-stones  and  cholecystitis  have  existed  independently  of  the 
appendical  disease,  as  in  the  cases  cited  in  Chap.  XVII.  When  the  association 
of  the  two  ailments  is  not  recognized,  and  only  one  is  cured  at  the  first  opera- 
tion, a  second  operation  has  sometimes  been  necessary  for  the  complete 
relief  of  the  symptoms. 

Pancreatic  Disease. — In  acute  pancreatitis  the  sudden  intense  epigastric 
pain,  abdominal  distention,  constipation,  and  vomiting  may,  at  the  outset,  sug- 
gest appendicitis.  The  most  important  differences  between  the  two  conditions 
are:  the  more  agonizing  and  persistent  pain  in  pancreatitis,  the  tenderness  on 
pressure  over  the  left  costal  margin,  and  the  profound  prostration,  which  is  often 
associated  with  marked  cyanosis.  The  age  of  the  patient,  a  history  of  alcoholism, 
and  more  particularly  a  history  of  gall-stones  are  important  in  the  diagnosis. 
The  temperature  is  usually  normal,  hut  the  pulse  accelerated.  The  presence  of 
fatty  stools  is.  of  course,  conclusive  evidence  of  pancreatic  disease.  Suppu- 
rative pancreatitis  is  accompanied  by  fever  and  may  closely  resemble  peritonitis 
due  to  a  ruptured  appendix.  Breweh  (loc.  cit.)  reports  the  case  of  a  man 
fifty-three  years  old,  who  had  presented  abdominal  symptoms  for  a  year,  and 
gave  a   history  of   peritonitis  occurring  seventeen   years   previously.     lie  was 


DIFFERENTIAL    DIAGNOSIS.  427 

suddenly  seized  with  abdominal  pain  accompanied  with  vomiting;,  fever,  and 
sweats.  The  abdomen  was  distended  and  generally  tender.  At  operation 
the  only  evidence  of  disease  was  the  presence  of  small  white  spots  covering 
the  omentum.  At  autopsy  the  pancreas  proved  to  contain  numerous  small 
abscesses. 

Gynecological  Affections. — Diseases  of  the  pelvic  organs  in  women  form 
the  most  important  class  of  cases  liable  to  be  mistaken  for  appendicitis,  and  vice 
versa.  The  differential  diagnosis  of  these  conditions  will  be  fully  considered 
in  Chap.  XXIX. 

Intramuscular  Abdominal  Abscesses. — These  have  been  mistaken  for  appen- 
dicitis with  localized  peritonitis.  They  are  distinguished  chiefly  by  the  absence 
of  intestinal  symptoms,  the  position  of  the  swelling,  and  sometimes  its  move- 
ment with  the  abdominal  walls.  Suppurative  appendicitis  is  not  uncommonly 
accompanied  with  edema  and  infiltration  of  the  overlying  abdominal  muscles, 
but  in  such  cases  there  are  the  distinctive  signs  of  a  deep-seated  affection 
and  the  history  of  appendiceal  inflammation.  The  primary  affection  may 
subside,  leaving  only  the  superficial  abscess,  as  in  a  case  admitted  to  the 
gynecological  ward  of  the  Johns  Hopkins  Hospital,  where  a  brawny,  diffuse 
swelling  in  the  abdominal  wall  over  the  right  iliac  fossa  was  found  to  be  an 
intramuscular  abscess.  This  was  freely  opened  and  drained,  when  complete 
recovery  followed,  but  later  on,  it  was  necessary  to  remove  the  adherent  appen- 
dix on  account  of  persistent  pain. 

Acute  Psoitis. — This  condition  may  set  in  with  sudden  severe  pain  and 
tenderness  in  the  right  iliac  region,  suggesting  an  acute  appendicitis.  The  pain, 
however,  extends  down  the  thigh  and  to  the  genital  organs.  The  thigh  is  flexed 
and  rotated  inward.  The  absence  of  intestinal  or  peritoneal  symptoms,  and 
the  usual  failure  of  acute  initial  symptoms,  are  the  distinguishing  points  in 
the  diagnosis;  the  chief  difficulty  in  it  being  due  to  the  frequent  involvement  of 
the  psoas  muscle  in  appendicitis,  but  in  such  cases  other  confirmatory  symptoms 
are  usually  found. 

Affections  of  the  Vertebrae  and  of  the  Hip-joint. — Appendicitis  devel- 
oping insidiously  and  accompanied  by  gradual  flexure  of  the  thigh,  or  with 
pain  in  the  lumbar  region  and  an  ill-defined  mass,  may  closely  simulate  a  lumbar 
abscess  or  a  coxitis.  I  have  not  met  with  a  case  of  genuine  vertebral  or  hip-joint 
disease  in  which  the  question  of  differential  diagnosis  from  appendicitis  caused 
great  perplexity  after  a  thorough  examination  had  been  made.  Cases  of 
erroneous  diagnosis  in  hip-joint  disease  in  children  have,  however,  been 
reported.  The  history  of  the  patient,  the  gradual  onset  of  the  attack,  the 
absence  of  intestinal  symptoms,  the  location,  direction,  and  character  of  the 
swelling,  and  usually  the  evident  deformity,  are  indications  which  should 
render  the  diagnosis  sufficiently  clear.  The  subject  is  fully  considered  in 
(Chap.  XX. 

Acute    osteo-myelitis    may,   however,   set   in  so  brusquely  and 


128  DIAGNOSIS. 

with  such  marked  abdominal  symptoms  that  at  first  considerable  confusion 
may  exist  as  to  the  diagnosis.  As  an  example  the  following  case  may  l>e 
given: 

\  student,  aged  seventeen  years,  was  admitted  to  the  surgical  departmenl  of 
the  Johns  Hopkins  Hospital  with  a  history  of  a  week's  illness,  which  began  while 

travelling  on  the  train  and  when  he  was  in  g 1  health,  with  sudden  pain  in  the 

hypogastric  region  so  severe  thai  he  was  doubled  up.  His  bowels  were  consti- 
pated and  micturition  painful.  He  was  nauseated  on  the  fourth  day,  but  there 
was  in)  vomiting.  The  pain  increased  and  shifted  to  the  Hanks,  and  when  the 
patienl  was  admitted  was  Idealized  in  the  righl  side  near  the  kidney  region.  He 
lay  with  both  knees  drawn  up  and  the  right  thigh  abducted,  not  being  able  to 
straighten  it  out  on  account  of  the  pain.  There  was  slight  fulness  in  the  hypo- 
gastric region  and  tenderness  low  down  over  the  righl  Poupart's  ligament.  Pres- 
sure here  elicited  acute  pain  and  apparently  voluntary  muscle  spasm.  The  ten- 
derness however,  seemed  superficial,  as  if  in  the  soft  parts  of  the  abdominal  wall. 
There  was  no  tenderness  in  the  hip-joint.  There  was  continuous  fever.  The  next 
day  the  right  thigh  was  distinctly  swollen,  indurated,  and  very  tender,  and  there 
was  also  swelling  over  the  symphysis,  l>ut  the  abdomen  was  otherwise  negative. 
Incision  into  the  swelling  showed  an  abscess  in  the  thigh  containing  a  pint  of  creamy 
pus.  extending  up  to  Poupart's  ligament,  but  not  into  the  pelvis. 

J.  B.  Deavee  relates  a  ease  of  gangrenous  appendicitis  in  which,  on  account 
of  the  history  of  injury  and  the  strongly  flexed,  abducted  right  thigh,  which  could 
not  he  moved  without  severe  pain,  a  dislocation  of  the  hip  was  suggested,  al- 
though the  pain  did  not  begin  until  the  day  after  the  injury  was  received.  The 
presence  of  marked  abdominal  distention,  tenderness,  and  rigidity  disclosed  the 
true  nature  of  the  attack. 

Hysteria  and  Hypochondriasis. — These  conditions  must  be  eliminated  from 
the  diagnosis  in  some  cases  of  suspected  appendicitis,  but  it  is  necessary  to  lie 
always  on  guard  against  assuming  a  nervous  manifestation  in  the  presence  of 
a  true  inflammation  of  the  appendix.  The  distinctive  features  in  the  differ- 
ential diagnosis  of  acute  attacks  are:  the  absence  of  fever  and  leucocytosis, 
and  tl;e  disappearance  of  local  tenderness  and  rigidity  when  the  patient  s  atten- 
tion is  diverted.  The  common  occurrence  of  digestive  disturbances  in  neurotic 
individuals  makes  the  recognition  of  chronic  appendicitis  more  difficult.  The 
palpation  of  the  thickened  appendix  is  sometimes  possible,  and  this  is,  of  course, 
conclusive.  Le  Roy  Brown  (Amer.  .lour.  Obst.,  July,  1004)  agrees  with  Manton 
of  St.  Louis  in  believing  that  visceral  delusions  in  the  insane  are  often  founded 
upon  the  presence  of  some  pathological  condition.  lie  relates  a  case  of  a  woman 
with  the  delusion  of  evil  spirits  in  the  abdomen,  from  whom  a  large,  inflamed 
appendix  was  removed.  Neuralgia  of  the  nerves  of  the  right  side  of  the  abdomen 
may  .simulate  appendicitis,  but  a  careful  examination  will  not  fail  to  reveal  the 
true   nature   of   the  ailment. 


DIFFERENTIAL    DIAGNOSIS.  429 

Intra-thoracic  Affections. — The  importance  of  recognizing  the  fact  that 
pneumonia  and  pleurisy,  particularly  in  children,  may  be  ush- 
ered in  with  acute  abdominal  symptoms,  has  recently  been  emphasized  by 
numerous  cases,  reported  by  Barnard,  Richardson,  Herrick  and  others, 
in  which  the  diagnosis,  at  first,  was  doubtful,  and  in  a  considerable  number 
operation  was  performed  for  supposed  appendicitis.  Out  of  24  cases  of  pneu- 
monia with  early  symptoms  referred  to  the  abdomen,  collected  by  Garreaxj 
(The*e  de  Paris,  1903),  .5  were  submitted  to  abdominal  section  for  acute  appen- 
dicitis. Pleurisy  or  basal  pneumonia  with  involvement  of  the  diaphragmatic 
pleura  seems  especially  liable  to  excite  acute  abdominal  symptoms,  but  a  pneu- 
monic focus  limited  to  the  right  upper  lobe  may  possibly  provoke  similar  phenom- 
ena, and  in  a  case  where  Herrick  was  called  upon  to  decide  as  to  the  advisabil- 
ity of  operation  for  appendicitis,  the  affection  was  located  in  the  left  lower  lobe. 
In  this  instance,  however,  the  symptoms  simulated  a  general  peritonitis  supposed 
to  be  of  appendical  origin,  although  the  right  iliac  region  was  not  especially 
involved.  The  attack  set  in  brusquely  with  severe  pain  in  the  abdomen,  fever, 
nausea,  and  vomiting.  In  such  cases  the  pain  may,  at  first,  be  general, 
and  is  sometimes  associated  with  marked  distention,  tenderness,  and  rig- 
idity. When  there  is  a  history  of  previous  trouble  in  the  right  iliac 
region,  as  in  a  case  described  by  Morris  (A".  5".  Med.  Jour.,  1899),  the 
clinical  picture  is  still  more  confusing.  The  most  important  distinguishing 
features  are:  the  suddenhigh  temperature,  which  often  ranges  from  103° 
to  106°  F.,  and  is  very  unusual  in  appendicitis,  together  with  the  rapid 
respirations,  which  are  often  increased  out  of  proportion  to  the  abdominal  symp- 
toms. The  tenderness  and  rigidity  are  usually  less  pronounced  than  in  true 
abdominal  inflammation.  Herrick  has  observed  that  the  cutaneous  hyperes- 
thesia i-  often  excessive,  while  steady,  quiet,  deep  palpation  will  not  increase  the 
pain ;  and  it  has  been  noticed  by  Barnard  that  the  abdomen  may  be  seen  to  yield 
slightly  at  the  beginning  of  inspiration.  The  high  leucocyte  count  may  be  a 
valuable  confirmatory  sign  in  doubtful  cases.  Da  Costa  states  that  the  leu- 
cocytosis  appears  early,  at  or  soon  after  the  initial  chill,  and  that  the  average 
"first  count''  is  22,693,  including  cases  which  fail  to  develop  an  increase.  In 
appendicitis,  on  the  other  hand,  the  increase  is  rarely  so  rapid.  However,  the 
main  safeguard  in  the  diagnosis,  as  expressed  by  Herrick,  is  to  bear  in  mind  the 
possibility  of  a  thoracic  origin  for  the  abdominal  symptoms.  It  will  then  gener- 
ally be  found  that  there  are  some  thoracic  symptoms,  and  a  careful  examination 
of  the  chest  will  reveal  some  loss  of  motion,  and,  on  auscultation,  one  or  other 
of  the  characteristic  signs,  albeit  extremely  slight,  will  usually  be  detected. 

Another  source  of  error  in  the  diagnosis  under  these  circumstances  is  the 
occasional  coexistence  of  appendical  and  thoracic  disease,  in  which  ease,  in  the 
presence  of  an  undoubted  pneumonia,  it  may  be  difficult  to  determine  whether 
the  abdominal  symptoms  are  merely  reflex  or  are  due  to  a  complicating  appen- 
dicitis.    W.  Finder  of  Troy,  X.  Y.    personal  communication),  saw  a  patient 


430  DIAGNOSIS. 

Buffering  from  an  evident  pneumonia  and  at  the  same  time  presenting  typical 
symptoms  of  appendicitis.  The  gangrenous  appendix  was  removed  by 
Boi  ston,  ami  the  patient  recovered  from  both  affections.  In  cases,  however, 
where  there  are  unmistakable  symptoms  of  acute  thoracic  disease  and  obscure 
symptoms  of  appendicitis,  the  latter  are  almost  invariably  reflex  in  origin.     There 

is  always  danger,  nevertheless,  of  too  great  i servatism  in  doubtful  cases,  and, 

as  Richardson  remarks:  "a  heavy  responsibility  rests  upon  those  who  advise 
delay  when  the  symptoms  point  to  a  general  peril  unit  is.  even  if  those  symptoms 
are  not  quite  what  they  should  be  in  typical  cases.  The  real  cases  of  appen- 
dicitis and  uf  general  peritonitis  as  compared  to  these  of  an  atypical  typhoid,  a 
latent  pneumonia,  or  some  other  unusual  simulating  lesion,  are  a  hundred 
to  one." 

The  Leucocyte  Count  as  an  Aid  to  Clinical  Diagnosis. —  In  certain  obscure 
abdominal  conditions  the  leucocyte  count  may  be  of  great  assistance  in  diagno- 
sis. A  high  leucocyte  count,  I'd. (l()()  or  more,  in  a  case  exhibiting  very  mild 
local  signs  and  symptoms  is  not  infrequent,  and  its  presence  enables  the  surgeon 
to  estimate  the  gravity  of  the  patient's  condition  and  authorizes  him  to  urge 
the  necessity  for  immediate  operation,  when  without  its  aid  both  surgeon  and 
patient  might  indulge  in  a  false  security.  A  low  leucocyte  count,  on  the  other 
hand,  must  nol  mislead  the  surgeon.  Our  present  knowledge  does  not  furnish 
any  definite  rules  for  the  use  of  the  leucocyte  count  in  diagnosis,  and  the  follow- 
ing general  rules  should  be  applied  only  after  taking  into  account  the  history, 
symptoms,  physical  signs,  and  all  other  factors  usually  considered  in  each  indi- 
vidual case. 

In  acute  appendicitis  without  complications  it  may  he  generally  stated  that 
the  leucocyte  count  increases  with  the  severity  of  the  disease,  an  increasing 
leucocytosis  indicating  an  increasing  inflammation;  the  contrary,  however. 
doc-  not  always  hold  true.  A  high  leucocyte  count  in  the  first  twenty-four 
hours  excites  great  apprehension,  for  it  is  suggestive  of  a  fulminating  inflamma- 
tion, with,  perhaps,  a  gangrenous  appendix.  A  leucocyte  count  above  15,000, 
occurring  at  the  end  of  an  attack,  when  the  local  symptoms  have  almost  disap- 
peared, generally  indicates  localized  pus.  When  local  abscess  formation  occurs 
in  the  early  stages,  the  leucocytes,  a-  a  rule,  are  high,  i.e.,  above  15,000.  Im- 
provement in  the  clinical  symptoms  after  the  fourth  day  i<  usually  accompanied 
by  a  falling  leucocytosis. 

If  operation  reveals  a  general  peritonitis,  a  moderate  leucocyte  count 
gives  a  better  prognosis  than  a  low  one.  since  the  latter  generally  indicates  a 
low  grade  of  resistance  in  the  patient.  A  very  high  leucocytosis.  ahove  2"), (ICO. 
is  a  grave  indication. 

With  a  chronic  abscess  the  count  is  usually  low.  hut  it  often  fluctuates  with 
exacerbations  of  the  local  symptoms. 


CHAPTER  XIX. 

APPENDICITIS  IN  TYPHOID  FEVER. 

HISTORY.     ETIOLOGY.     DIAGNOSIS.     TREATMENT. 

In  typhoid  fever  the  great  and  immediate  source  of  anxiety  to  the  watchful 
physician  is  the  possibility  of  p  r  o  f  o  u  ml  toxemia  or  septicemia, 
of  hemorrhage,  or  of  perforati  o  n  .  Aside  from  these  grave  com- 
plications, however,  a  host  of  lesser  ills  are  liable  to  arise  intercurrently.  For 
example,  on  the  right  side  of  the  body  there  lies  a  chain  of  organs,  extend- 
ing from  the  liver  to  the  pelvis,  whose  links  are  the  gall-bladder, 
the  renal  pelvis,  the  v  e  rmiform  appendix,  and  the 
u  v  i  n  a  r  y  b  ladder  ,  any  one  of  which  is  liable  to  become  the  source 
of  an  infection  during  the  typhoid  attack,  long  outlasting  the  original  dis- 
ease. Only  one  of  these  organs,  however,  the  appendix,  is  apt  to  give  rise  to 
an  acute  disturbance  in  the  midst  of  the  fever.  Infections  of  other  organs,  re- 
sulting in  cholecystitis,  pyelitis,  and  cystitis  of  the 
urinary  bladder,  manifest  themselves,  as  a  rule,  at  a  later  date,  and  become 
most  prominent  as  sequela1,  more  or  less  remote.  Inflammation  of  the  ap- 
pendix is  an  intercurrent  affection  which  is  liable  to  assume  its  greatest  im- 
portance at  the  very  beginning  of  the  fever,  or  else  when  it  is  at  its  height. 

If  the  typhoid  patient  is  seized  with  an  appendicitis,  it  is  manifestly  of  the 
utmost  importance  to  recognize  the  fact  promptly,  and  in  suitable  cases  to 
interfere  for  its  relief,  in  order  that  the  vital  powers,  already  taxed  to  their 
utmost,  may  not  be  reduced  to  their  lowest  ebb  by  two  coincident  exhaustive 
conditions.  The  decision  whether  or  not  to  institute  operative  proceedings  for 
an  appendicitis  developing  in  the  course  of  typhoid  fever  becomes,  therefore, 
one  of  the  gravest  responsibility.  On  the  one  hand,  the  surgeon  has  to  bear 
in  mind  that  an  appendicitis  under  these  conditions  is  woefully  like  a  powder 
magazine  attached  to  a  lighted  fuse,  which  may  go  out  quietly,  but  may,  on 
the  contrary,  explode  the  mine  at  any  moment,  unless  the  fire  is  extinguished 
by  prompt  interference  at  all  hazards.  Yet,  on  the  other  hand,  if  the  surgeon 
is  over-zealous  in  operating,  and  interferes  merely  because  some  of  the  symptoms 
of  appendicitis  are  present,  the  event  may  prove  that  his  interference  was  unne- 
cessary, and  he  will  then  have  to  endure  the  chagrin  of  finding  that  he  has  added 
a  useless  and  serious  operation  to  the  gravity  of  an  already  distressing  situation. 
Moreover,  the  man  who  makes  such  a  mistake  cannot  hope  to  escape  the 
reproaches  of  the  family,  and  should  the  patient  die  at  any  time  during  the  course 

431 


132  APPENDICITIS    IN"    TYPHOID    FEVER. 

of  the  disease,  the  natural  tendency  of  the  human  mind  to  find  relief  from  sor- 
row in  anger  will  almost  certainly  bring  upon  him  the  blame  for  the  fatal  result. 
The  responsibility  of  a  surgeon  summoned  to  decide  for  or  againsl  opera- 
tion under  such  circumstances  has  been  graphically  described  by  M.  II. 
Richardson  {Bost.  Med.  and.  Surg.  Jour.,  Jan.  9,  1903).  "  Operations  during 
the  course  of  typhoid,  even  those  operations  which  in  themselves  are  compara- 
tively slight,  have  a  high  mortality.  The  surgeon  must  be  always  on  his  guard 
[esl  he  fail  i"  recognize  typhoid  fever,  not  only  in  its  ordinary  forms,  bul  in  its 
unusual  and  atypical  aspects,  and  subject  his  patient  to  an  operation,  which, 
even  if  apparently  made  necessary  by  the  clinical  evidence,  is  entirely  unjusti- 
fied  by  the  pathological   findings." 

History. — The  condition  of  the  vermiform  appendix  in  typhoid  fever  seems 
first  tn  have  received  attention  a1  the  hands  of  a  Frenchman,  Jadelot,  in  1808 
(see  also  Chap.  I,  p.  3).  In  describing  the  case  of  a  boy  of  thirteen,  who  died 
of  a  "  fiirrr  adynamique,"  accompanied  toward  the  close  by  symptoms  of 
ataxia,  the  writer  says  that  the  autopsy  showed  a  lesion  at  the  end  of  the  ileum 

exactly  like  those  which  M.  Petit,  at  the  lintel  hint,  attributed  to  the  fever 
called  l'entero-jm4senteYique,''  while  the  different  parts  of  the  intestine  were 
found  filled  with  lumbricoid  worms,  four  of  which  occupied  the  enlarged 
cavity  of  the  appendix,  one  of  them  being  doubled  on  itself. 

The  next  reference  to  the  appendix  in  typhoid  fever,  if  1  am  not  mistaken,  is 
the  account  of  a  distinct  perforation  described  in  a  paper  on  peritonitis  arising 
from  ulceration  and  perforation  of  the  appendix,  by  an  Italian,  Carlo  De 
\  i  i enr,  in  IMS  (see  also  Chap.  II,  p.  IS).  The  case,  which  is  given  in  a  foot- 
note, was  related  to  the  writer  by  another  physician,  Robecchi,  who.  when 
making  a  postmortem  on  a  sailor,  dying  unexpectedly  on  the  seventh  day  of 
typhoid  fever,  found  a  perforation  of  the  appendix  near  the  insertion  of  the 
organ  into  the  cecum  crAr  tagliando,  .  .  .  il  cadavere  <li  uu  marinajo, 
morto  quasi  improvvisamente  in  settima  giornata  di  febbre  tifoidea,  trovd  un' 
ulcera  perforata  ndl'  ajipendirc  in  ricinanza  dcUa  di  lei  inserzione  net  ceco"). 

Buhl  (Zeitschr.  j.  rat.  Med.,  L854,  X.  F.,  Bd.  I.  p.  342)  gives  an  admirable 
description  of  three  fatal  cases  of  typhoid  fever,  in  each  of  which  there  was  an 
ulcerative  perforation  of  the  appendix.  At  the  time  these  occurred,  every  fourth 
patient  in  the  hospital  had  typhoid  fever,  and  in  the  course  of  two  and  a  half 
months,  three  out  of  five  autopsies  made  on  typhoid  victims  showed  perfo- 
ration of  the  appendix.  One  was  in  a  woman  of  twenty,  dying  on  the  twenty- 
fourth  day  of  the  disease,  who,  apart  from  the  usual  lesions  of  typhoid,  had  a 
genera]  purulent  peritonitis,  with  an  appendix  completely  amputated  by  a  perfo- 
rating ulcer  just  above  its  blind  end.  The  second  case  was  that  of  a  man,  also 
twenty  years  old,  who  began  to  grow  worse  about  the  fourteenth  day  of  his  illness, 
and  died  on  the  twentieth.  The  autopsy  showed  the  usual  typhoid  changes, 
with  general  peritonitis,  and  an  ulcerative  perforation  of  the  appendix  near  its 
tip.     The  chief  difference  between  these  two  cases  lay  in  the  fact  that  in  the 


HISTORY.  433 

first,  abscesses  were  found  in  the  upper  lobes  of  the  left  lung,  which  was  otherwise 
anemic.  One  death  resulted  simply  from  the  peritonitis  occasioned  by  perfo- 
ration of  the  appendix,  while  in  the  other  case  there  was  pyemia,  appar- 
ently originating  earlier  than  the  peritonitis  by  which  death  was  hastened. 
Buhl  remarks  that  a  pyemic  process  originating  in  the  appendix  may  follow 
one  of  two  channels:  either  lodging  in  the  lungs,  as  in  the  case  just  described, 
or  entering  the  portal  system  and  travelling  to  the  liver.  He  then  describes 
a  portal  pyemia  originating  in  the  vermiform  appendix,  after  protective  ad- 
hesions had  insured  the  patient  against  the  dangers  of  a  fatal  peritonitis. 
His  third  case  is  that  of  a  young  man,  nineteen  years  old,  who  died  twenty- 
six  days  after  the  beginning  of  his  illness.  His  symptoms  were  icterus,  a  liver 
enlarged  to  twice  its  natural  size,  stools  colored  with  bile  (without,  however, 
any  bile  in  the  urine),  recurring  chills,  and  pain  in  the  region  of  the  liver.  The 
autopsy  showed  an  empyema  of  the  appendix,  which  contained  a  fecal  concretion, 
and  had  a  perforated  extremity  associated  with  an  abscess  the  size  of  a  hazel- 
nut, walled  off  from  the  peritoneum.  A  sinus  led  between  the  layers  of  the 
mesentery  to  the  portal  vein,  while  the  adjacent  veins  were  filled  with  in- 
fectious purulent  debris  (jauche).  The  portal  branches  of  the  liver  were  filled 
with  pus  and  there  were  large  parenchymatous  abscesses.  Buhl  calls  particu- 
lar attention  to  this  case  on  account  of  the  rarity  of  suppurative  pylephlebitis. 
Although  he  includes  it  among  the  three  typhoid  cases,  he  says  nothing  of  the 
condition  of  Fever's  patches. 

Three  years  later  a  case  of  perforation  of  the  appendix  in  typhoid  fever  was 
reported  in  the  United  States  by  Sands,  who  presented  the  specimen  to  the 
New  York  Pathological  Society  (Amer.  Med.  Month.,  1S57,  vol.  7,  p.  231).)  The 
patient,  a  man  twenty-two  years  old,  was  overcome  by  exhaustion  ami  fainted 
while  occupied  in  his  profession  as  an  artist.  He  recovered  in  a  short  time, 
however,  sufficiently  to  resume  his  work  for  some  hours,  and  ate  his  dinner,  soon 
after  which  he  was  seized  with  severe  pain  in  the  right  iliac  region,  with  great 
prostration  and  vomiting.  There  was  tenderness  in  the  right  iliac  fossa,  greatly 
increased  by  pressure,  while  other  parts  of  the  abdomen  were  free  from  pain. 
He  also  had  headache,  constipation,  and  great  nervous  prostration.  The  next 
day  he  was  worse,  and  a  diagnosis  of  a  sloughing  appendix  was  made.  The  pain 
in  the  abdomen  became  general,  although  it  continued  to  be  worst  on  the 
right  side.  Death  occurred  on  the  fourth  day.  At  the  autopsy  the  appendix 
was  found  fastened  to  the  back  of  the  cecum  by  adhesions.  It  was  distended 
by  a  fecal  concretion,  in  which  were  found  a  number  of  strawberry  seeds  and 
solid  particles.  The  mucosa  was  the  seat  of  sloughing  ulceration,  with  a  per- 
foration near  the  extremity,  permitting  the  escape  of  fecal  matter,  and  causing 
the  acute  peritonitis  of  which  the  patient  died.  The  solitary  and  agminated 
glands  of  the  small  intestine  were  diseased,  "  having  the  appearance  which 
they  often  present  in  typhoid  fever." 

Frequency. — Rolleston  {Lancet,  May  29,  1898)  says  that  nut  of  60  cases  of 
28 


|:;i  APPENDICITIS    l\   TYPHOID    FEVER. 

enteric  fever  examined  al  St.  George's  Hospital,  the  appendix  was  found  to 
be  altered  in  1 1.  In  5  of  this  Dumber  ii  was  simply  swollen,  in  7  ulcerated, 
and  in  2  perforated.  Perforation  bad  occurred  in  1 1  per  cent.  ou1  of  the  entire 
ti()  (including  those  in  the  appendix).     Other  statistics  arc  as  follows: 

(    \>i  S  '  'I    Tl  PHOID  PeRFOH  ITION 

Fever  wti  h  Situated  im 

Perforation.  ihe  Appendix. 

Heschl  (reported  by  Wagner,  Schmidfs  Jahrbuch.,  1853, 

vol.  80,  p.  42) 56  8 

Morin  {Thesi  d<  Paris,  1867) 64  12 

Chi  k<  ii  {Records  of  St.  Bartholomew's  Hospital.  1SS1,  vol 

17.  p.  97) 21  3 

Fitz  (Bost.  Med.  and  Surg.  Jour.,  1891,  vol.  25,  p.  346) . .  1(>7  5 

Cushing  {Records  Johns  Hopkins  Hospital,  1899-1900) . .  20  2 

ETIOLOGY. 

A)  i]  Kin  licit  is  may  appear  during  typhoid  fever  under  t  lie  following  conditions : 

1.  The  appendicitis  may  be  purely  accidental,  that  is  to  say,  appendicitis 
and  typhoid  fever,  both  of  which  are  common  maladies,  may  by  accident  be 
found  concurrently  in  the  same  individual;  or  a  latent  or  chronic  inflammation 
of  the  appendix  may  be  roused  into  activity  by  typhoid  fever. 

'J.  An  appendicitis,  of  a  mild  or  of  a  severe  type,  may  arise  from  a  typhoid 
affection  of  thi'  lymph  glands  or  from  an  ulcer  situated  in  the  appendix,  and 
may  even  go  on  to  perforation. 

:!.  Appendicitis  may  follow  typhoid  fever,  appearing  within  such  a  brief 
time  after  the  subsidence  of  the  fever  as  to  strongly  suggesl  a  causal  rela- 
tionship. 

Appendicitis  Occurring  Coincidentally  with  Typhoid  Fever,  or  Roused 
into  Activity  by  it. — I  fail  to  find  any  satisfactory  instance  of  simple  acute 
appendicitis  occurring  during  the  course  of  typhoid  fever.  A  latent  or  chronic 
appendicitis  may  be  roused  into  activity  during  the  course  of  typhoid  fever 
in  several  different  ways,  in  the  first  of  which  the  query  which  suggests 
suggests  itself  is  :  If  the  p  a  t  i  e  n  t  has  a  small  coll  e  c- 
t i  on  of  pus  in  the  a  p  pend  ix  will  the  accession 
of  t  y  p  h  o  i  d  f  e  ver  suffice  to  l>  r  i  n  g  o  n  a  n  a  c  u  t  e  at- 
tack of  appendicitis?  I  have  found  hut  one  (doubtful)  case  in 
which  this  condition  is  recorded  to  have  occurred,  which  was  published  by  F. 
Bossard  {Ueber  die  Verschwarung  und  Durchbohrung  des  Wurmfortsatzes,  I.  D. 
Zurich.    1869,   Case  25). 

If  the  appendix  is  a  c  ill  id  y  flex  e  d  .  o  r  is  c  r  OSS  e  d  1)  y 
li  a  n  d  s  o  f  ad  h  e  s  i  o  n  s  ,  will  the  s  welli  n  <r  i  n  ci  d  e  n  t  t  o  a 
t  y  ph  o  i  d  a  f  f  e c t  i  o  n  of  the  g] a  n  d  u 1  a  r  t  i  s  s  u e  s e r v e  t  o 
p  r  0  d  U  C  e  an  attack  of  appendicitis0  I  know  of  no  data  with 
which  to  answer  this  question.    It  is,  however,  an  important  one,  for  the  discom- 


ETIOLOGY.  435 

fort  occasioned  by  any  deviation  from  the  normal  in  the  appendix  is  apt  to  arouse 
the  suspicion  of  disease  in  the  patient's  mind,  and  should  an  attack  of  typhoid 
lever  occur,  it  may  be  mistaken  in  its  initial  stages  for  appendicitis,  because  both 
patient  and  physician  are  preoccupied  with  that  idea.  In  two  instances  within 
my  own  knowledge,  physicians  who  had  themselves  suffered  for  more  than 
a  year  with  repeated  attacks  of  pain  in  the  right  iliac  fossa,  were  seized  with 
typhoid  fever,  accompanied  in  each  case  with  acute  distress  in  the  right  inguinal 
region,  and  were  convinced  that  a  severe  complication  requiring  operation  had 
arisen.  In  one  case,  operation  disclosed  the  appendix  surrounded  by  adhesions 
and  partially  obliterated,  but  not  acutely  inflamed  ;  in  the  other,  in  which  the 
appendix  was  flexed,  there  was  nothing  more  than  the  changes  so  often  observed 
in  it  in  connection  with  typhoid  fever;  in  neither  case  would  the  operation 
have  been  performed  could  the  surgeon  have  known  beforehand  the  condition 
of  the  organ.     (See  Cases  1  and  2,  pp.  44.~>,  440.) 

If  there  is  a  foreign  body  within  the  appendix,  will 
its  action  as  an  irritant  upon  the  swollen  mucosa  serve 
to  h  r  i  n  g  about  a  n  acute  i  n  f  1  a  in  ma  t  i  o  a  ?  I  have  found  but 
four  cases  in  which  a  foreign  body  is  noted  to  have  been  present  in  typhoid 
appendicitis,  and  one  of  these  really  supervened  at  the  end  of  the  fourth 
week,  when  the  temperature  had  been  almost  normal  for  two  days. 

In  this  connection  I  should  mention  that  L.  J.  Hammond  (Jour.  Aim r.  Med. 
Assoc,  April  16,  1904)  considers  thai  an  antecedent  appendicitis  is  liable  to 
prove  a  serious  complication  should  the  patient  contract  typhoid  fever,  and  in 
proof  of  this  statement  he  cites  a  case  in  which  there  was  an  extensive  rupture 
of  the  ileum,  at  a  point  1  to  12  cm.  above  the  valve,  the  postmortem  demonstrat- 
ing that  the  tension  caused  by  the  adhesion  of  the  appendix  to  the  lateral  peri- 
toneum favored  solution  in  the  continuity  of  the  bowel  at  the  point  of  ulceration, 
and  was  responsible  for  the  tremendous  rent  that  took  place. 

True  Typhoid  Appendicitis. — The  character  of  the  lesions  of  true  typhoid 
appendicitis  has  already  been  shown  in  the  section  on  pathology  (see  Chap.  XIII), 
where  we  have  seen  that  the  appendix  may  participate  in  all  the  changes  to 
which  the  agminated  glands  are  liable.  The  first  suggestion  of  this  possibility 
appears  to  have  been  in  the  discussion  following  the  report  of  Sands'  case  (loc. 
cit.).  After  reading  his  paper,  he  inquired  of  the  Society  whether  any  other 
than  an  accidental  relationship  might  be  supposed  to  exist  between  the  disease 
in  the  appendix  and  that  in  the  intestines:  and  if  so,  which  should  be  regarded 
as  antecedent.  The  greater  intensity  of  disease  in  the  appendix  favored  the 
idea  that  it  had  proceeded  from  below  upward ;  it  might  be,  however,  thai  in  the 
present  case  the  concretion  would  have  remained  harmless  had  not  an  addi- 
tional source  of  irritation  been  furnished  by  the  extension  of  disease  which  had 
begun  in  the  small  intestine.  Harris  said  that  his  experience  tended  to 
confirm  the  latter  view,  he  having  in  several  instances  noticed   ulceration  of 


136  APPENDICITIS    IN'    TYPHOID    FEVER. 

the  follicles  of  the  appendix,  coincideni  with  ulceration  of  Peyer's  plates  in 
typhoid  fever. 

The  uexl  expression  of  opinion  to  this  effect,  which  T  find,  is  thai  of  Norman 
M :i:  {Trans.  Path.  Soc.  Lond.,  1883,  vol.  34),  who  remarks:  "II  has  some- 
times 1 ii  though!  thai  ulcers  in  this  situation  were  previous  to,  or  indepen- 

denl  of  the  fever,  bu<  the  fact  thai  in  four  cases  cited  there  was  extensive  general 
ulceration,  makes  it  probable  thai  the  ulceration  of  the  vermiform  appendix 
occasionally  presenl  in  typhoid  fever,  has  the  same  relation  to  the  fever  as  ulcer- 
ation of  other  parts  of  the  large  intestine." 

().  Hopfenhausen  (Rev.  de  la  Sui  eRom.,  1899,  torn.  19,  p.,  105)  has  inves- 
tigated the  condition  of  the  appendix  in  typhoid  fever  in  thirty  autopsies,  and 
found  thai  in  every  instance  the  appendix  was  affected  to  a  greater  or  less  ex- 
tent, varying  from  a  mere  hyperemia  of  the  mucosa  to  extensive  ulceration. 

I  have  myself  investigated  the  subjeel  by  collecting  from  literature,  from 
hospital  records,  and  from  personal  communications,  30  cases  reported  in  more 
or  less  detail,  in  which  the  condition  of  the  appendix  during  typhoid  fever  was 
demonstrated  by  operation  or  by  autopsy,  in  most  of  which  there  had  been 
symptoms  of  appendicitis  during  the  course  of  the  typhoid.  In  5  cases  the  micro- 
scope gave  evidence  of  typhoid  ulcers  within  the  appendix;  in  1  there  was  ulcer- 
ation without  perforation;  in  Hi  perforation;  in  1  appendicitis  with  abscess; 
in  I  a  simple  congestion  with  a  perforation  situated  in  the  ileum;  and  in  the 
remaining  7  there  were  adhesions,  flexions,  or  obliterative  changes.  I  would 
al-o  call  attention  to  II.  CHRISTIAN'S  valuable  statistics,  taken  from  119 
autopsies  in  typhoid  patients,  in  which  19  showed  changes  sufficienl  to  com- 
mand attention  (see  Chap.  X.   p.   25). 

From  all  these  sources  we  have  convincing  proof  that  true  typhoid  appen- 
dicitis does  occur,  further  supported  by  the  clinical  evidence  afforded  by  other 
cases  which  have  recovered  without  operation.  It  is  a  matter  of  common 
observation  thai  early  in  the  course  of  typhoid  fever  patients  often  complain 
of  marked  pain  in  the  right  iliac  fossa,  and  this  is  probably  due,  in  most  instances, 
to  involvement  of  the  appendix  associated  with  swelling  and  tension,  which 
there  is  every  reason  to  believe  accompanies  the  typhoid  lesions  in  the  intestine 
in  all  cases. 

I  subjoin  brief  abstracts  of  the  .">  cases  in  which  microscopic  evidence  of 
typhoid  ulci  ration  within  the  appendix  was  obtained. 

1.  .1.  Ii.  Murphy,  Is'.t:;  (/„ r.ioiml  communication).  A  woman,  twenty-two 
years  old,  was  ill  for  five  days  with  headache  and  general  malaise,  hut  not  confined 
to  bed.  She  then  began  to  have  severe  abdominal  pain  with  great  tenderness  in  the 
right  iliac  fossa,  followed  by  vomiting.  The  temperature  was  103.2  F.  A  diagnosis 
was  made  of  appendicitis  and  operation  immediately  performed.  The  appen- 
dix was  swollen  to  twice  its  natural  size,  but  there  was  DO  point  of  threatened  per- 
ioral ion.     Tlie  ileum  contained  a  number  of  Peyer's  patches  in  process  of  typhoid 


TRUE    TYPHOID    APPENDICITIS.  437 

ulceration.     Microscopic  examination  of  the  appendix  showed  a  classical  typhoid 
lesion.     The  patient   went   through   a   typical   typhoid   fever,   and   recovered. 

2.  Ibid.,  1893.  A  woman,  age  not  given,  was  ill  for  two  days  with  head- 
ache and  pain  in  the  back.  At  the  end  of  that  time,  when  she  consulted  a  phy- 
sician, her  temperature  was  103.5°  F.  It  continued  to  rise  steadily  until  the 
fourth  dav,  when  she  was  seized  with  severe  abdominal  pain,  followed  by  nausea 
and  vomiting.  Twenty-four  hours  later  there  was  extreme  sensitiveness  all  over 
the  lower  abdomen,  especially  in  the  right  iliac  fossa,  but  no  induration,  although 
the  area  of  the  appendix  could  be  outlined  from  the  muscular  resistance.  A  diag- 
nosis was  made  of  acute  and  infective  appendicitis,  and  operation  performed  on 
the  fifth  da)'.  The  appendix  was  enlarged  at  the  cecal  attachment :  the  distal 
end  contained  muco-purulent  matter;  the  proximal  end  an  ulcer.  The  ileum 
showed  numerous  typhoid  patches.  Microscopic  examination  of  the  appendix 
showed  the  ulcer  to  be  a  typical  typhoid  one;  the  patient  went  through  an  ordinary 
attack  of  the  disease  and  recovered. 

3.  Ibid.,  1894.  A  girl,  fourteen  years  old.  was  indisposed  for  more  than  two 
weeks,  but  able  to  continue  at  work  until  the  end  of  that  time,  when  she 
had  a  severe  attack  of  pain  in  the  abdomen,  followed  by  nausea  and  vomiting. 
Examination  of  the  abdomen  showed  no  unusual  tympany,  but  the  appendix  could 
be  outlined,  and  was  found  very  sensitive.  On  operation,  it  proved  non-adherent, 
but  there  was  a  grayish  exudate  on  the  mesenteric  side  of  an  enlarged  and  indurated 
nodule  at  the  junction  of  the  outer  and  middle  third.  Microscopic  examination 
of  the  appendix  showed  that  it  contained  a  classical  typhoid  ulcer.  The  patient 
went  through  a  typical  typhoid  fever  and  recovered. 

4.  J.  H.  H.,  Sept.,  1900.  Surg.  Xo.  10940.  A  negro,  twenty-one  year- 
old,  was  admitted  with  typhoid  fever,  about  the  seventh  clay  of  the  disease. 
The  Widal  reaction  was  positive  on  the  sixth  day.  On  the  ninth  day  there  was 
some  tenderness  about  the  navel,  and  the  next  day  at  McBurney's  point.  On  the 
twelfth  day  the  pain  and  sensitiveness  were  much  greater,  and  the  leucocytes  had 
increased  from  7.700  at  8  a.m.  to  8. 500  at  10  p.m.  On  the  thirteenth  day,  there 
was  definite  muscular  spasm  in  the  right  iliac  fossa,  and  the  leucocytes  had  in- 
creased to  20.000;  there  was  general  rigidity  on  palpation,  both  recti  being  tense, 
and  marked  tenderness  present  over  the  whole  area  of  protective  spasm.  <  to  opera- 
tion, the  peritoneum  was  found  inflamed,  and  there  were  two  inflamed  IVyer's 
patches  in  the  ileum.  The  appendix,  which  lay  behind  the  cecum,  was  distended, 
tense,  and  rigid,  its  surface  vessels  large  and  tortuous,  presenting  the  appearance 
of  acute  inflammation.  Microscopic  examination  showed  a  typical  typhoid  con- 
dition. The  patient  improved  for  a  few  hours,  but  died  from  typhoid  septicemia 
two   days   after   the   operation. 

.").  B.  McMonagle.  Califor.  Acad,  of  Med.,  Feb.  25.  1901.  A  man.  eighteen 
years  old,  began  to  suffer  from  cpistaxis.  headache,  and  malaise,  and  two  days 
later  he  had  a  slight  chill,  with  nausea  and  vomiting.  His  temperature  was 
101.6°  F.  On  the  thirteenth  day.  rose  spots  were  observed,  and  on  the  fourteenth, 
the  Widal  reaction  was  positive.  On  the  fifteenth  day  the  patient  had  an  attack 
of  very  severe  pain  in  the  abdomen,  and  the  temperature,  which  had  been  about 
101°  F.,  rose  to  105°  F.     Examination  showed  considerable  general  tenderness 


138  APPENDICITIS    IX   TYPHOID   FEVER. 

in  the  abdomen,  increased  in  the  right  iliac  fossa;  the  muscles  were  teise  to  the 
point  of  spasm  on  slighl  pressure,  and  there  was  apparent  increased  tub*  -  in 
the  right  flank.  Electa!  examination  showed  tenderness  in  the  recto-vesica  '- 
de-sac,  particularly  on  the  ri<rlit  side.  The  spleen  was  enlarged,  the  liver  du 
normal,  and  the  leucocytes  17,000.  Operation  showed  the  appendix  tenseh  lis- 
tended  in  the  middle  and  outer  thirds,  congested,  and  hemorrhagic,  with  an  irea 
of  necrosis  6  mm.  in  diameter.  The  canal  was  patulous,  and  the  mucosa  of 
the  proximal  third  swollen  and  necrotic.  In  the  remaining  portion  were  several 
deep  ulcerations  extending  at  one  point  to  the  peritoneum.  Microscopic  exam- 
ination showed  a  typical  typhoid  ulcer  at   the  proximal  third. 

Post-typhoid  Appendicitis.— The  fact  that  a  true  typhoid  appendicitis 
exists  naturally  suggests  the  question :   Can    the    debris    of    such    i  n  - 

ction  linger  in  the  appendix  undischarged,  await- 
ing a  favorable  opportunity  to  produce  an  attack 
of  appendicitis  some  time  after  the  patient  has 
completely  recovered  from  the  typhoid?  And,  again, 
can  the  t  y  p  h  o  id  u  1  c  e  rati  o  n  p  roduce  such  a  n  a  r  - 
rowing  of  the  lumen  of  the  appendix  as  will  serve 
to  obstruct  its  d  i  s  ch  a  r g e  s ,  and  so  f a  v  o r  a  n  at- 
tack   o  f    a  p  pendicitis     at     s  o  m  e     future    t  i  m  e  ? 

HopiF.xiiAt  skx  (be.  cit.)  has  especially  considered  the  possibility  of  such 
a  causal  relation  between  typhoid  fever  and  appendicitis,  and  has  collected 
statistics  concerning  it  from  thirteen  different  sources,  (hit  of  748  cases,  there 
were  oti  in  which  there  was  a  history  of  previous  typhoid,  the  interval  of  time 
between  the  two  diseases  being  as  follows:  In  5  cases,  from  twenty-four  to  forty 
years;  in  24  cases,  from  ten  to  twenty  years;  in  2  cases,  three  years;  in  ]  case, 
two  years;  in  1  case,  one  year;  and  3  cases,  from  two  to  six  months.  Hut, 
as  she  points  out,  although  the  condition  of  the  appendix  in  every  case 
resembled  catarrhal  appendicitis,  it  could  nol  be  a  true  catarrh,  since  the  interval 
of  time  between  the  two  diseases  in  the  majority  from  ten  to  forty  year- 1  forbids 
the  assumption  of  any  connection  between  them.  The  attention  of  clinicians. 
however,  has  nol  as  yet  been  sufficiently  directed  to  this  important  point,  and 
it  may  yet  lie  found  that  typhoid  fever  victims  are  more  prone  than  others  to 
appendicitis.  I  would  suggest  that  a  note  as  to  infectious  diseases,  especially 
typhoid,  should  lie  carefully  added  to  the  history  of  even'  appendicitis,  ami  fur- 
ther that  all  patients  should  he  questioned  a-  to  any  unusual  pain  in  the  right 
iliac  fossa  in  the  course  of  the  typhoid.  If  any  frequent  causal  relation-hip 
exist,  our  hospitals  will  probably  supply  the  data  from  ex-typhoid  cases  dis- 
charged from  the  medical  wards,  ami  returning  at  a  later  date  to  the  surgical 
service. 

The  following  cases  are  all  in  which  a  post-typhoid  appendicitis  has  come 
within  my  own  cognizance: 


POST-TYPHOID    APPENDICITIS.  439 

'.  H  H.,  May,  1899.  Surg.  Xo.  10940.  A  man,  forty-eight  years  old,  was 
adn  tted '  complaining  of  abdominal  pain.  In  September,  eight  month-  before, 
1       fad  had  an  attack  of  typhoid,  with  which  he  was  in  bed  for  three  months  and 

two  severe  hemorrhages.  He  had  also  some  pain  in  the  right  iliac  fossa  with 
a  L  .  alized  tumor  slightly  tender  on  pressure  in  that  region.  Constipation  was 
marked  during  the  attack  and  after  convalescence.  ( >n  entrance  he  was  suffering 
from  severe  pain  in  the  lower  abdomen,  especially  on  the  right  side,  and  the 
bowels  had  not  moved  for  six  days. 

In  the  next  case  furnished  by  S.  Crowell,  Dorchester,  Mass.,  appendicitis 
developed  at  the  end  of  the  fourth  week,  at  the  period  of  almost  complete 
defervescence. 

A  boy,  seven  years  old,  had  a  mild,  uneventful  attack  of  typhoid  fever  which 
completed  its  course  favorably  at  the  end  of  the  fourth  week.  On  the  third  day, 
when  the  morning  temperature  had  become  normal,  while  the  evening  temperature 
was  only  99.5°  F.,  he  was  attacked  by  abdominal  pain  and  vomiting,  with  a  rise 
of  temperature  to  over  100°  F.  When  seen,  thirty-six  hours  later,  the  temperature 
was  104°  F.,  there  was  pain  and  tenderness  over  the  abdomen,  increased  over  the 
appendix,  rigidity  of  the  muscles,  and  vomiting.  There  was  no  distention  of  the 
abdomen,  but  the  patient  looked  ill.  An  immediate  operation  was  performed, 
showing  the  appendix  dark  red  and  swollen;  there  was  an  escape  of  fluid  from 
the  peritoneum,  with  a  distinct  fecal  odor,  but  there  was  no  perforation.  A  small 
ovoid  concretion  was  found  in  the  appendix.     The  patient  recovered. 

I  have  met  with  two  cases  in  which  typhoid  fever  has  followed  operation  for 
appendicitis,  and  I  here  give  a  brief  account  of  each,  as  they  seem  to  be 
extremely  unusual. 

C.  F.  Nassau  (personal  communication,  1902).  A  woman  of  thirty-five  was 
suffering  from  recurrent  appendicitis  for  which  operation  was  advised  and  refused. 
Seven  months  later  she  had  an  attack  of  acute  appendicitis,  and  the  appendix 
was  removed,  together  with  the  right  ovary  (which  was  cystic)  and  the  tube:  the 
uterus  was  suspended.  Two  clays  afterward  it  was  necessary  to  re-open  the  ab- 
domen, on  account  of  symptoms  of  obstruction,  and  an  old  fan-shaped  adhesion 
was  found,  obstructing  the  hepatic  flexure  of  the  colon.  The  temperature  fell 
to  normal  in  six  days,  and  then  began  to  rise.  This  was  ascrib  d  to  several  stitch 
abscesses  occasioned  by  the  silkworm  sutures  being  tied  too  tightly  at  the  second 
operation.  The  patient  then  became  suddenly  delirious,  with  extreme  abdominal 
distention.  Typhoid  fever  was  suspected,  and  also  pelvic  pus  collection.  Vagina] 
puncture  was  made,  but  there  was  no  pus.  On  the  twenty-second  day  after  the 
second  operation  the  AVida]  reaction  was  positive.  The  twenty-third  day,  there 
was  severe  hemorrhage  from  the  bowels,  and  on  the  twenty-fourth  day,  death  oc- 
curred from  one  of  large  size. 

H.  A.  Pttlsford  (personal  communication.  1904).  The  patient,  a  physician, 
was  taken  suddenly  ill  with  severe  abdominal  pain  followed  by  serious  symptoms 
necessitating  immediate  operation.  The  appendix  proved  to  be  gangrenous  and 
perforated,  there  were  no  adhesions    and  a  genera]  peritonitis  was  beginning.     It 


•Ill)  APPENDICITIS    IN    TYPHOID    FEVER. 

was  necessary  to  make  an  incision  on  the  left  side  of  the  abdomen  as  well  as  on 
the  right,  and  both  wounds  were  lefl  open  with  generous  drainage.  The  patient 
was  profoundly  septic  for  a  time,  and  the  wounds  were  not  entirely  closed  until 
five  months  alter  the  operation.  The  appendix  was  examined  only  macroscopic- 
ally.  Aliuut  three  months  after  the  operation,  while  the  wounds  were  still  par- 
tially open,  the  patient  went  to  <  >ld  Poinl  Comfort  for  a  few  days,  and  two  weeks 
alter  his  return  he  developed  typhoid  fever  of  moderate  severity.  There  were 
no  complications,  bu1  alter  recovery  the  patient  had  a  perichondritis  on  the  left 
side,  which  clid  not,  however,  proceed  to  suppuration.  He  had  also  a  peripheral 
neuritis  affecting  the  superficial  nerves  of  the  feet,  producing  first  hyperesthesia 
and  then  anesthesia,  and  persisting  for  several  month-. 


DIAGNOSIS. 

The  decision  for  or  against  an  operation  for  appendicitis  in  a  patient  who  lias 
typhoid  fever  is  a  matter  of  the  utmost  gravity,  and  the  preliminary  question 
of  diagnosis  therefore  becomes  one  of  prime  importance.  When  symptoms  of 
the  fever  are  not  yet  fully  developed,  the  first  question  to  be  settled  is:  Has 
t  h  e  p  a  t  i  e  n  t  a  p  pendicitis,  o  r  h  a  s  h  e  t  y  p  h  o  i  d  I'  e  v  e  r  ? 
In  some  cases  an  immediate  positive  answer  is  impossible,  bill  where  there  is 
strong  reason  to  suspeci  typhoid  fever,  and  at  the  same  time  one  or  more  of  the 
characteristic  symptoms  of  appendicitis  are  lacking,  it  is  well  to  give  the  patient 
the  heiielit  (if  the  doubt  and  to  defer  decision  while  keeping  him  under  close 
observation  by  both  physician  and  surgeon.  A  case  of  appendicitis  clearly  de- 
manding immediate  interference  ought  to  present  the  syndrome  of  pain, 
t  e  n  d  e  r  n  e  s  s  ,  muscular  r  i  g  i  d  i  t  y  ,  and  f  e  v  e  r  .  Richardson 
(Bost.  Mul.  mi/}  Surg.  Jour..  Jan.,  1002)  says:  "  Let  any  of  these 
symptoms  be  absent,  and  doubt  as  to  the  existence  of  an  acute  appen- 
dicitis arises.  A  peritonitis  localized  about  the  appendix  is  at  once  ex- 
cluded, though  it  is  more  than  likely  that  there  is  some  appendicular  lesion. 
So  with  pain  and  rigidity  in  the  right  iliac  fossa,  the  absence  of  tenderness  would 
at  once  rouse  serious  doubts  a-  to  the  existence  of  appendicitis.  Pain,  rigidity, 
and  tenderness,  without  fever  would  lie  the  least  doubtful  combination,  for 
absence  of  fever  is  sometimes  conspicuous  in  really  serious  local  infections  of  the 
peritoneum.  When  typhoid  fever  is  suspected,  one  or  more  unusual  combinations 
of  the  lour  symptoms  just  mentioned  will  prevail.  The  accurate  observer  cannot 
but  be  on  his  guard.  For  example,  let  there  he  pain  and  tenderness  in  the  right 
iliac  fossa. with  fever,  but  without  rigidity:  The  surgeon  must  account  for  the 
absence  of  rigidity  before  he  opens  the  abdomen.  lie  must  inquire  into  a  pre- 
vious malaise.  He  must  inquire  most  minutely  into  the  history  of  the  pain  itself, 
its  manner  of  onset,  its  relations  with  temperature  and  pulse,  its  early  and  late 
situation.  He  must  inquire  about  the  prevalence  of  typhoid  in  the  community. 
Every  abdominal  and  thoracic  organ  must  be  carefully  examined.  He  must, 
furthermore,   make  exhaustive  examinations  of  the  blood.     All   this  care  is 


DIAGNOSIS.  441 

imperative  in  the  absence  of  a  single  symptom — rigidity  of  the  abdominal  muscles. 
Another  example :  Assume  that  in  a  questionable  case  of  acute  abdominal  disease 
there  has  been  no  pain,  but  there  is  tenderness,  rigidity,  ami  fever.  The  absence 
of  painful  onset  ami  of  present  pain  at  once  suggests  something  out  of  the  com- 
mon. A  temperature  of  104°  to  105°  1\,  with  gradually  appearing  tenderness 
and  rigidity,  is  so  unusual  in  appendicitis  that  that  disease  can  almost  certainly 
be  ruled  out,  owing  to  the  absence  of  pain  alone.  Tenderness  and  rigidity 
must  be  accounted  for  by  other  lesions.  Indeed,  it  is  so  hard  to  imagine  a 
disease  in  which,  without  pain  at  one  time  or  another,  there  is  fever,  local  tender- 
ness, and  rigidity,  that  one  can  almost  say  that  the  combination  of  these  three 
symptoms  alone — fever,  tenderness,  and  rigidity — is  an  impossible  one  in  acute 
abdominal  disease.'' 

The  W  i  d  al  reaction,  which  is  so  valuable  in  the  diagnosis  of  typhoid 
fever,  unfortunately  often  fails  to  develop  before  the  seventh  to  the  tenth  days, 
and  in  some  instances  it  is  as  late  as  the  fourth,  fifth,  or  sixth  weeks.  It  should 
always  lie  tried,  however,  as  the  patient  may  have  a  latent  typhoid.  The  value 
of  the  agglutinative  test  is  so  great  that  it  will  determine  the  diagnosis  when  pres- 
ent. The  absence  of  this  sign  in  early  cases,  however,  must  not  influence  a 
decision. 

The  leucocyte  c  o  u  n  t  is  a  most  valuable  aid  in  making  a  differential 
diagnosis  in  cases  where  doubt  rests  between  an  acute  appendicitis  and  a  typhoid 
fever  simply  beginning  its  protracted  course,  with  a  temporary  focusing  of 
the  symptoms  in  the  right  iliac  fossa.  The  leucocytes  in  typhoid  fever  are 
always  low,  probably  reaching  their  highest  point,  eight  to  ten  thousand,  in 
epidemic  cases,  in  the  first  three  or  four  days  of  the  disease.  The  count  never 
mounts  up,  but  tends  to  descend  rapidly.  Boland  has  shown  that  the  sub- 
cutaneous injection  of  typhoid  toxins  produces  a  decrease  of  the  leucocytes. 
In  such  metastatic  affections  as  pleurisy,  and  pneumonia  due  to  typhoid 
organisms  it  is  also  the  rule  for  the  leucocyte  count  to  remain  low.  In  typhoid 
fever  the  mononuclear  leucocytes,  especially  the  large  ones,  are  increased,  while 
the  rule  in  inflammatory  disease  is  for  the  polvmorpho-nuclear  leucocytes  to  in- 
crease. But  although  the  leucocyte  count  is  a  valuable  aid  to  diagnosis,  it  may 
prove  woefully  misleading  in  exceptional  instances,  when  the  rule  that  typhoid 
fever  inhibits  leucocytosis  fails  to  hold.  In  one  case  (see  p.  446)  the  patient 
had  a  leucocytosis  of  10,000,  which  rose  in  3  days  to  18,000;  the  diagnosis  of 
appendicitis  was  then  made  and  operation  performed,  but  no  serious  disease 
was  discovered.  In  the  second  (see  p.  438)  there  was  a  leucocytosis  of  17.000, 
and  on  operation  a  typhoid  ulcer  was  found  in  the  appendix  without 
perforation. 

Curschmaxx  (" Der  Unterleibstyphus,"  Wien,  1898,  p.  177)  states  that 
in  typhoid  fever  a  common  evidence  of  the  disturbance  of  the  digestion  of  albu- 
men is  found  in  the  presence  of  moderate, or  even  large  amounts  of  ind  i  can 
in  the  urine.     There  is  no  particular  relationship,  however,  between  the  occur- 


l\2  APPENDICITIS    IN   TYPHOID    FEVER. 

rence  of  the  indican  and  the  intensity  of  the  infection,  and  its  presence  has, 
therefore  no  special  diagnostic  or  prognostic  value;  indeed,  in  light  ca 
particularly  those  associated  with  diarrhea  or  obstinate  constipation,  the  indican 
reaction  is  often  more  marked  than  in  tin-  Beverer  forms  of  the  disease ;  when 
t  aeral  peritonitis  supervene.-,  or  such  a  localized  peritonitis  as  occurs  in  the 
limited  forms  of  appendicitis  (peri  t  y  phi  i  t  i  s  t  y  p  h  o  s  a),  the  excre- 
tion of  indican   is   not    particularly   marked. 

It  occasionally  happens  that  a  localized  peritonitis  without  perforation  exists 
around  a  typhoid  ulcer,  giving  rise  to  sufficient  adhesions  and  inflammatory 
products  to  form  a  tumor  which  may  simulate  appendicitis.  <  »n  the  other 
hand,  protective  and  adhesive  peritonitis  localized  in  the  neighborhood  of  the 
appendix  occasionally  follows  perforation  of  a  typhoid  ulcer  with  tumor  forma- 
tion, which  also  simulate  appendicitis.  Such  a  case  was  reported  byH.L.  Elsner 
.V.  )".  Med.  Jour.,  April  9,  1893),  in  which  there  was  perforation  of  a  typhoid 
ulcer  followed  by  adhesive  and  protective  peritonitis,  and,  finally,  tumor  forma- 
tion, with  symptoms  simulating  appendicitis  so  closely  thai  a  differential  diag- 
nosis was  made  with  great  difficulty.  The  patient  finally  died  of  intestinal  hem- 
orrhage, and  autopsy  showed  that  a  coil  of  the  ileum,  beginning  aboul  5  inches 
from  the  ileocecal  valve,  had  folded  itself  againsl  the  bend  of  the  colon  laterally. 
and  was  firmly  held  there  by  inflammatory  products.  There  was  no  evidence 
of  escape  of  intestinal  contents.  A  perforation  of  a  typhoid  ulcer  2  em.  in 
length  was  found  in  the  portion  of  the  ileum  resting  directly  against  the  colon. 
So  perfectly  was  the  perforation  sealed  that  no  gas  escaped  during  the  autopsy 
until  the  ileum  was  lifted  from  its  resting-place  againsl  the  colon.  Fitz  (Bott. 
."!/<'/.  "/"/  Surg.  Jour.,  <  >ct.  8,  1901,  p.  365) :  "  Most  cases  ol  recovery  from  symp- 
toms of  perforation  of  the  bowel  in  typhoid  fever  are  those  in  which  an  attack 
of  appendicitis  is  closely  simulated,  while  the  fatal  cases  of  perforation  of  the 
bowel  in  typhoid  fever  are.  in  the  great  majority  of  instances,  those  in  which 
other  parts  of  the  bowel  than  the  appendix  are  the  seat  of  a  perforation.  Hence 
the  prognosis  of  apparent  perforation  in  typhoid  fever  i-  to  be  regarded  as  the 
more  favorable,  the  more  closely  the  symptoms  and  course  resemble  those  of 
appendicitis. " 

The  second  diagnostic  question  to  lie  answered  is:  If  the  patient 
has  typhoid  fever,  has  he  appendicitis  also'.'  And  if  he 
has  appendicitis,  what  is  its  grade'?  The  diagnosis  of  appendicitis 
must  rest  upon  the  characteristic  local  symptoms  of  an  inflamed  appendix, 
supervening  upon  the  already  existing  symptoms  of  typhoid  fever.  There 
is  reason  to  s  u  s  p  e  c  t  an  i  n  v  o  1  ve  m  e  n  t  of  the  a  p  p  e  n  d  i  x 
i  n  e  v  e  r  y  <■  a  s  e  w  h  e  r  e  -  e  v  e  re  p  a  i  n  .  distinctly  1  o  c  a  1  i  z  e  d 
tenderness,  a  n  d  muscular  rigidity  exist  in  the  r  e  is  i  o  n 
of  the  right  iliac  fossa.  The  earlier  the  stage  of  the  disease  in 
which  these  symptoms  appear,  however,  the  more  should  the  physician  be 
upon  his  guard  in  assuming  that  the  complication  is  grave  enough  to  demand 


DIAGNOSIS.  443 

operation.  I  know  of  but  two  cases  in  which  a  perforation  of  the  appendix 
lias  been  noticed  as  early  as  the  eighth  day.  Later  in  the  disease,  that  is  to  say. 
in  the  latter  part  of  the  second  or  in  the  third  week,  the  sudden  supervention  of 
severe  inflammatory  symptoms  in  the  right  iliac  fossa  raises,  not  so  much  the 
particular  question  whether  there  is  an  appendicitis  or  whether  the  appendix 
is  perforated,  as  the  question  of  an  intestinal  perforation  in  general,  whether 
in  the  ileum  or  in  the  appendix.  Under  such  circumstances  the  particular 
location  of  the  perforation  is  a  matter  of  minor  importance. 

There  seems  to  be  no  defined  set  of  symptoms  which  can  be  denominated 
pre-perforative.  The  physician  must  always,  of  course,  give  the  closest  atten- 
tion to  any  unusual  complaints  of  pain  in  the  right  iliac  fossa  occurring  during 
typhoid.  "When  a  perforation  occurs,  there  is  apt  to  be  a  sudden  acute  pain 
accompanied  by  a  fall  in  temperature.  The  sudden  defervescence  is  also  noted 
in  hemorrhage,  but  without  the  pain.  Intestinal  hemorrhage  occurred  in 
four  out  of  ten  cases  of  perforation  of  the  appendix  several  days  before  perfo- 
ration took  place,  the  pain  coining  on  with  the  perforation.  The  occurrence 
of  a  hemorrhage,  therefore,  must  put  the  physician  on  his  guard,  in  anticipating 
a  possible  perforation.  In  addition  to  pain  and  fall  of  temperature,  there  are 
marked  evidences  of  collapse,  such  as  change  in  the  facial  expression,  a  small 
weak  pulse,  nausea,  abdominal  swelling,  general  tenderness,  and  signs  of  gas 
in  the  peritoneal  cavity,  with  the  disappearance  of  the  liver  dulness.  Free 
fluid  in  the  abdominal  cavity  must  not  be  mistaken  for  an  accumulation  of 
fecal  material;  they  can  be  distinguished  by  the  fact  that  the  fluid  is  easily 
displaced  by  some  change  in  the  position  of  the  patient. 

Cueschmaxx  has  called  attention  Hoc.  cit.)  to  a  particularly  interesting 
group  of  cases,  occurring  more  frequently  than  the  profession  are  aware,  in 
which  an  inflammation  of  the  peritoneum  localized  in  the  right  iliac  fossa  occurs 
during  typhoid  fever  and  which  he  designates  peri-  or  para-typhlitis 
t  y  p  h  o  s  a  .  The  perforation  of  the  peritoneum  is  extremely  minute,  or  there 
may  be  only  an  excessive  thinning  of  the  intestinal  wall,  without  rupture,  to 
account  for  the  surrounding  peritoneal  inflammation.  The  seat  ot  the  affec- 
tion corresponds  to  the  inflammatory  tumors  of  the  appendix.  In  true  typhoid 
appendicitis  the  perforation  also  plays  an  important  role.  Curschmann  has 
occasionally  found  deep  ulcers  with  most  minute  perforations  in  the  cecum, 
especially  in  the  neighborhood  of  the  valve,  and  also  on  the  border-line 
between  tlie  cecum  and  colon,  which  afford  an  explanation  of  circumscribed 
inflammations  in  the  right  iliac  fossa.  This  p  er  i  t  y  phli  t  is  t  y  p  h  o  s  a 
is  sometimes  found  at  that  stage  when  peritonitis  is  most  apt  todevelop,  but 
rather  more  frequently  later  in  the  disease,  or  even  during  convalescence.  He 
has  himself  observed  it  once  on  the  eighteenth,  and  once  on  the  twenty-first 
day,  at  a  time  when  the  patient  was  free  from  fever. 

The  local  manifestations  of  such  a  typhoid  perityphlitis  are  in  all  respects 
similar  to  other  inflammatory  processes  in  the  right  iliac  fossa:   they  appear  as 


Ill  APPENDICITIS    IN    TYPHOID    FEVER. 

painful,  more  or  less  extensive,  resistant,  circumscribed  infiltrations,  which, 
apparently,  lead  to  abscess  Formation  more  readily  than  is  the  case  in  ordinary 
appendicitis.  In  one  instance  there  was  a  retro-peritoneal  abscess  which  was 
successfully  opened  in  the  back.  He  lias  also  noted  some  cases  in  which  a  period 
of  general  malaise,  with  irregular  fever  and  an  enlarged  spleen,  bul  without  diar- 
rhea or  rose  spots,  was  followed  by  a  perityphlitis  which  at  once  established  a 
correct  diagnosis.  In  other  cases,  where  a  diagnosis  of  simple  perityphlitis 
(appendicitis)  had  been  made,  the  history  of  a  febrile  disturbance  preceding  the 
perityphlitis  for  two  or  three  weeks  aroused  the  suspicion  of  a  typhoid  peri- 
typhlitis, the  actual  existence  of  which  was  proved  by  the  fact  that  the  dis- 
ease then  ran  a  typical  course,  or  else  by  the  occurrence  of  a  characteristic 
typhoid  relapse. 

A  neglected  appendicitis  in  which  the  patient  falls  into  a  "typhoid"  condi- 
tion from  the  absorption  of  the  septic  products,  must  he  carefully  distinguished 
from  true  typhoid  appendicitis  or  perityphlitis.  Curschmann  recalls  one  case 
in  which  the  development  of  a  parotitis  during  the  course  of  the  disease  seemed 
to  point  to  typhoid  fever,  but  the  complication  proved  in  the  end  to  have  arisen 
from  an  abscess  in  the  right  iliac  fossa. 

A  number  of  cases  have  been  reported  in  which  typhoid  fever  has  been 
mistaken,  during  its  early  stages,  for  an  appendicitis;  the  reverse,  namely, 
to  mistake  appendicitis  for  typhoid  fever,  is  a  much  rarer  accident.  I  quote, 
therefore,  the  following  case: 

C.  R.  B<>x  and  C.  S.  Wallace  {Lancet,  1904,  vol.  1.  p.  1588).  A  man  fifty 
years  eld  was  taken  ill  suddenly  with  pain  in  the  right  iliac  fossa.  His  tempera- 
ture was  high  (102.2°  l.i.  his  pulse  120  and  intermittent,  and  he  was  mildly  de- 
lirious at  night.  He  had  slight  diarrhea,  with  pea-soup,  offensive  stools,  and  in 
the  third  week  of  his  illness  he  had  three  large  hemorrhages  of  bright  red  blood 
from  the  bowels,  and  a  diagnosis  of  typhoid  fever  was  made.  There  were  no  rose 
spots,  and  no  agglutinative  reaction  on  examination  of  the  Mood:  the  test  was  not 
made,  however,  until  late  in  the  illness.  Death  took  place  on  the  twenty-first  daw 
At  the  autopsy  an  abseess  was  found  in  the  right  iliac  fossa,  hut  the  appendix  could 
not  he  recognized.  There  was  no  trace  of  typhoid  ulceration  in  either  large  or 
small   intestine. 

TREATMENT. 

In  a  case  of  suspect  e  d  a  ppendicitis  w  i  t  h  an  alt  e  r  n  a  - 
t  i  v  e  diagnosis  of  t  y  p h  o i  d  f  e  v  e r  the  wisest  course 
is  to  wait.  The  best  general  rule  is  not  to  operate 
for  appendicitis  in  t  h  e  earl  y  s  t  a  g  e  s  of  t  y  p  h  o  i  d 
fever — say.  up  to  about  the  tenth  day — in  the  ab- 
sence of  exceedin  g  1  y  urgent  sy  m  p  t  o  m  s  ;  give  the  patient 
the  benefit  of  the  doubt,  wait,  and  watch  closely.  The  clinical  history  of 
the  collected  cases  seems  to  show  that,  with  the  rarest  exceptions,  there  is  no 


TREATMENT.  445 

more  occasion  for  operating  upon  a  true  typhoid  appendix  than  there  is  for 
cutting  clown  upon  the  ileum,  and  excising  the  affected  fever's  patches. 

This  rule  of  delay,  except  in  extreme  urgency  of  symptoms,  accords  with 
the  established  practice  of  some  of  our  best  operators.  J.  B.  Murphy  of  Chicago, 
for  example,  after  operating  upon  three  cases  in  which  the  symptoms  of  appen- 
dicitis were  pronounced,  and  finding  that  the  lesions  in  the  appendix  revealed 
by  microscopic  examination  were  those  of  a  typical  typhoid  condition,  refused 
to  operate  upon  the  next  five  in  his  practice,  presenting  similar  symptoms,  and  in 
each  instance  the  subsequent  course  of  the  disease  justified  the  decision.  In 
a  personal  communication  he  says :  "It  is  my  opinion  that  typhoid 
appendicitis  should  not  be  operated  upon,  unless 
there  is  a  perforation.  All  my  cases  recover,  those 
operated  and  not  operated.  At  the  same  time,  I  feel 
that  operation  should  not  be  per  formed,  e  x  c  e  p  t  i  n 
special  cases.'' 

There  prevails  in  some  quarters  a  strong  tendency  to  operate  in  typhoid 
fever  as  soon  as  symptoms  of  appendicitis  appear,  this  course  of  action  being 
encouraged  both  by  the  swollen  condition  of  the  appendix  as  found,  as  well  as 
by  the  favorable  outcome  of  the  operation.  The  surgeon  in  such  a  case  con- 
gratulates himself  that  he  has  obviated  a  serious  complication  of  the  disease 
at  what  he  considers  little  or  no  risk  to  the  patient.  This  would  be  the  case 
if  the  microscopic  appearance  cf  the  typhoid  appendix  had  the  same  significance 
as  that  of  an  ordinary  inflamed  appendix,  but  experience  shows  that  this  is  not 
true.  The  inference  that  a  swollen  typhoid  appendix  must  shortly  advance 
to  gangrene  or  perforation  is  not  warranted  by  the  well-established  facts.  Per 
contra,  when,  after  a  siege  of  pain  in  the  right  iliac  fossa,  the  patient  lapses  into 
an  ordinary  typhoid,  with  an  entire  subsidence  of  the  severe  local  symptoms, 
the  observer  must  not  hastily  conclude  that  he  was  wrong  in  suspecting  an 
involvement  of  the  appendix  in  the  first  instance.  The  autopsy  records  show, 
as  I  have  said,  that  the  appendix  is  often  much  swollen,  but  that  this  condi- 
tion is  a  frequent  accompaniment  of  the  early  stages  of  the  disease. 

That  operation  in  the  early  stages  of  typhoid  fever  for  symptoms  suggestive 
of  appendicitis  may  be  precipitate  is  shown  by  the  results  in  seven  of  my  col- 
lected cases,  in  which  the  morbid  changes  connected  with  the  appendix  were 
insufficient  to  justify  the  increased  risk  to  the  patient  incurred  by  operation. 

1.  J.  H.  II..  March,  1902.  Sura;.  No.  13153.  A  physician,  twenty-seven 
years  old,  had  numerous  severe  attacks  of  colicky  pain  suggestive  of  appendicitis, 
during  two  years.  At  the  end  of  that  time  he  began  to  suffer  with  continued  ab- 
dominal pain,  most  marked  in  the  right  iliac  fossa,  and  general  malaise,  being  con- 
fined to  bed  for  a  few  days  at  the  outset.  This  condition  persisted  for  several 
weeks,  during  which  time  his  temperature  was  normal,  when  the  pain  at  last  became 
localized  in  the  right  iliac  fossa,  convincing  him  that  he  had  appendicitis  and  caus- 
ing him  to  enter  a  hospital.     The  abdomen  was  flat  and  soft,  and  there  was   no 


446  APPENDICITIS    IN    TYPHOID    FEVER. 

mass.  At  the  operation,  on  the  day  of  admission,  the  appendix  was  found  adherent 
beneath  the  cecum,  and  coiled  on  itself;  it  was  not  inflamed,  bu1  surrounded  by 
dense  adhesions.  Microscopic  examination  showed  marked  obliterative  changes, 
converting  the  greater  part  of  the  organ  into  a  fibrous  cord.  After  the  operation 
the  temperature  fuse  steadily  to  104°  1-'.,  and  on  the  sixth  day  there  was  an  intes- 
tinal hemorrhage.  A  few  fuse  spots  were  found,  and  the  spleen  was  palpable. 
The  leucocytes,  which  on  the  fourth  day  were  8,000,  decreased  to  6,000  on  the 
sixth.  (»n  the  tenth  and  eleventh  days  the  patient  had  several  severe  hemorrhages, 
and   on   the   twelfth   he   died.     There   was   no  autopsy. 

2.  M.J.  Lewis  (personal  communication,  I'.kil'i.  !■'.  A.  P.,  a  physician,  forty- 
one  years  old.  had  vague  pains  in  the  region  of  the  appendix  for  eighteen  months, 
which  caused  him  some  anxiety.  lie  was  taken  ill  with  typhoid  fever,  and  on  the 
seventh  day  developed  marked  tympany,  with  pain  on  pressure,  and  over  McBur- 
ney's  point  slighl  rigidity  of  both  recti;  the  leucocytes  were  about  10,000.  The 
Widal  reaction  was  positive.  On  the  fourteenth  day  the  leucocyte  count  rose- 
to  14,800,  and  on  the  fifteenth  to  18,400.  Operation  was  then  done  and  showed 
the  appendix  free  from  adhesions,  hut  Hexed  on  a  short  mesappeiidix  ;  the  ileum 
was  congested,  dark  red,  ami  much  thickened.  An  enlarged,  inflamed  Peyer's 
patch  was  seen,  and  the  mesenteric  glands  were  greatly  swollen.  The  mucosa 
of  the  appendix  was  also  much  swollen,  gray,  translucent,  and  studded  with  punc- 
tate hemorrhages;  near  the  cecal  end  was  a  small  area  like  a  swollen  Peyer's  patch. 
The  only  organism  presenl  was  the  b  a  cill  us  c  <>  1  i  .  The  microscope  showed 
diffuse  increase  of  lymphoid  and  epithelial  cells,  with  small  veins  and  capillaries  packed 
with  polymorpho-nuclear  leucocytes,  which  in  many  instances  seemed  almost 
to  plug  the  vessels.  The  increase  of  mononuclear  white  cells,  usually  seen  in 
typhoid  fever,  was  lacking.  On  the  eighteenth  day  of  the  disease  the  leucocytes 
fell  to  6,400,  and  the  polymorpho-nuclear  percentage  was  91.6;  marked  tympany 
appeared,  followed  by  chill.  On  the  twentieth  day,  or  six  days  after  the  opera- 
tion, the  wound  had  not  united,  the  stitches  were  removed,  and  the  serous  coat 
was  seen  to  lie  quite  normal.  The  wound  was  closed  on  the  twenty-fifth  day.  On 
the  thirty-first  day  (the  seventeenth  after  the  operation)  after  a  period  of  con- 
siderable distention,  and  a  leucocyte  count  varying  from  7,000  to  10,000,  there 
was  a  sudden  increase  to  11,200,  while  the  temperature  fell  to  07°  F.  The  upper 
abdomen  became  greatly  distended,  with  visible  peristalsis  of  the  transverse  colon. 
The  wound  was  again  opened,  and  two  fingers  introduced,  bu1  no  point  of  adhe- 
sions could  he  found,  although  the  transverse  colon  was  enormously  distended. 
On  the  thirty-sixth  day  there  was  a  sudden  collapse  of  the  colon,  with  escape  of 
gas  and  feces  from  the  open  wound.  Immediate  operation  showed  a  ragged  necro- 
tic opening  on  the  under  side  of  the  transverse  colon.  Death  occurred  on  the 
thirty-seventh  day:    there   was  no  autopsy. 

3.  A.  J.  Ochsner  (personal  communication,  1904).  A  trained  nurse,  twenty- 
three  years  old.  was  taken  ill  while  on  duty,  with  excruciating  pain  in  the  abdo- 
men. The  abdominal  walls  were  thickened,  and  moderately  distended  by  gas; 
there  was  nausea,  but  no  vomiting.  The  temperature  was  100°  F.  A  diagnosis 
of  acute  perforating  appendicitis  was  made,  and  operation  performed  ten  hours 
alter  the  onsel  of  the  attack,  when  the  temperature  had  fallen  three  degrees,  and 


TREATMENT.  447 

the  pain  was  still  diffuse,  although  the  tenderness  was  much  more  marked  at 
McBurney's  point.  The  muscular  rigidity  on  the  right  side  which  had  given  the  im- 
pression of  an  inflammatory  mass  in  the  region  of  the  appendix  disappeared  under 
anesthesia.  The  patient  had  the  appearance  of  extreme  illness,  while  the  day 
before  she  was  the  picture  of  health.  On  operation  the  peritoneum  was  found 
congested  over  all  the  intestines  in  sight,  including  the  appendix,  which  was  re- 
moved. Nothing  abnormal  was  found  in  it,  and  the  patient  passed  through  a 
typical  attack  of  typhoid  fever,  lasting  five  weeks,  and  ending  in  recovery. 

4.  E.  E.  Montgomery  (personal  communication,  1903).  A  boy,  eight  years 
old,  had  continuous  pain  for  two  days  in  the  right  abdomen,  with  distention, 
gurgling,  and  rather  marked  tenderness,  muscular  resistance,  and  a  temperature 
of  104°  F.  A  diagnosis  of  appendicitis  was  made,  and  the  operation  was  done 
on  the  same  day.  The  appendix  was  free  from  inflammation,  but  was  bent  at  an 
angle,  and  quite  patulous.  The  patient  then  passed  through  an  attack  of  typhoid 
fever,  extending  over  three  weeks,  and  ending  in  recovery.  The  diagnosis  was 
confirmed  by  the  Widal  reaction. 

5.  W.  J.  Hearn  (personal  communication,  1904).  A  boy,  seven  years  old, 
was  brought  to  the  Jefferson  College  Hospital  by  a  competent  physician  with  a 
diagnosis  of  appendicitis.  He  had  marked  tenderness  in  the  right  iliac  fossa  and 
a  temperature  of  101°  F.  Operation  on  the  following  day  showed  the  ileocecal 
valve  much  injected,  as  well  as  the  peritoneal  coat  of  the  appendix  and  the  cecum. 
The  appendix  was  removed,  but  there  was  no  obstruction  of  its  lumen  nor  a  fecal 
concretion.  A  diagnosis  of  typhoid  fever  was  made  during  the  operation  from 
the  appearance  of  the  intestines.  The  patient  passed  through  an  ordinary  attack 
of  typhoid  fever  of  moderate  severity,  lasting  four  weeks. 

6.  J.  H.  H.,  August,  1899.  A  trained  nurse,  twenty-eight  years  old,  was 
taken  ill  with  cramps  in  the  abdomen,  diarrhea,  and  nausea,  but  no  vomiting. 
These  symptoms  were  followed  by  severe  headache,  loss  of  appetite,  and  fever. 
About  a  week  later  she  had  a  chill,  and  after  that  severe  aching  pain  over  the 
whole  abdomen,  especially  in  the  right  iliac  fossa,  which  continued  irregularly  for 
six  days.  Two  weeks  from  the  onset  the  leucocytes  were  10,000,  the  next  day 
14, Slid,  and  the  temperature  102.5°  F.  A  diagnosis  of  appendicitis  was  made. 
and  at  the  operation,  two  days  later,  the  appendix  was  found  lightly  adherent, 
with  the  outer  half  of  its  peritoneal  coat  injected.  Microscopic  examination 
showed  obliteration  throughout,  the  centre  consisting  of  old  fibrous  tissue,  with 
slight,  round  cell  infiltration.  Three  days  later  she  developed  marked  typhoid 
symptoms,  and  the  temperature  was  102.5°  F.  ;  the  Widal  reaction  was  positive 
four  clays  after  operation.  She  went  through  a  normal  typhoid  course  with  two 
relapses. 

7.  (See  post-typhoid  appendicitis  case,   p.   439.) 

The  question  as  to  operation  later  in  the  disease  depends,  not  so  much  upon 
the  diagnosis  of  an  appendicitis  as  upon  the  occurrence  of  perforation  of  the 
bowel,  without  respect  to  its  anatomical  site.  The  symptoms  in  order  to  justify 
operation  must  be  of  a  more  urgent  character  than  would  be  necessary  in  the 
case  of  a  person  in  perfect  health  suddenly  affected  in  a  similar  manner,  as  the 


IIS  APPENDICITIS    IN   TYPHOID    FEVER. 

greater  gravity  of  an  operation  in  the  heighl  of  typhoid  fever  warrants  the 
surgeon's  assuming  greater  risks  in  waiting  to  make  sure  thai  an  operation  is 
inevitable.  If  the  classical  symptoms  of  perforation  arc  present,  the  operator 
will,  of  course,  proceed  at  once,  without  making  any  attempt  to  refine  his 
diagnosis  as  t<>  the  exact  site  of  the  lesion.  It  would  seem  h  priori  probable 
that  the  chances  of  a  patient  with  a  perforation  of  the  appendix,  disposed  as 
thai  organ  is  "  in  a  quiel  corner  of  the  abdomen"  i  II.  Ci  shing),  would  be  better 
than  with  a  perforation  of  the  ileum,  more  centrally  situated.  The  reeords 
show,  however,  that  of  seven  operations  in  which  a  perforation  was  found  in 
the  appendix,  but  one  recovered. 

The  operation,  once  decided  upon,  should  be  performed 
with  promptitude,  and  minutes,  rather  than  hours, 
counted  precious  in  m  a  k  i  ng  t  h  e  p  r  e  p  a  rations.  If  the 
operator  is  familiar  with  the  endermic  use  of  cocain  in  surgical  operations,  he 

will  often  do  belter  to  open  the  abdomen  under  a  cocai ■  a  coca'm  adrenal 

solution  (see  p.  517,  Chap.  XXIII),  than  risk  the  clangers  of  struggling,  and  the 
depressing  influence  of  a  general  anesthetic. 

It  is  best  to  make  a  free  incision  in  the  right  semilunar  line,  and  evacuate 
all  purulent  and  fecal  material,  after  which  the  appendix  can  be  tied  off  at  its 
base  and  removed.  If  necessary,  other  incisions  may  be  made  for  more  efficient 
direct  drainage.  In  all  such  operations  the  condition  of  the  ileum,  if  easily 
accessible,  should  be  noted,  in  order  to  ascertain  whether  it  is  congested  or 
exhibits    diseased    l'eyer's    patches. 

The  operator  should  always  bear  in  mind  the  possibility  of  a  perforation  in 
the  ileum  as  well  as  in  the  appendix,  as  found  in  one  out  of  my  30  cases.  He 
should  also  discover  and  turn  in  by  sutures  any  Peyer's  patch  which  seems 
just  about  to  perforate. 

If  a  perforation  is  found  in  the  ileum,  which  is  small  in  size,  and  the  surround- 
ing tissues  appear  healthy  enough  to  hold  the  sutures,  the  simplest  and  best  plan 
is  to  turn  the  opening  into  the  bowel,  and  close  it  by  two  or  three  fine  mattress 
sutures.  Where  there  is  a  general  peritonitis  and  extravasation  of  fecal  con- 
tents, the  abdomen  should  be  washed  out  with  a  warm  solution  and  drained. 
When  there  is  excessive  tympany  with  peritonitis,  it  is  sometimes  besl  to  fix 
a  loo])  of  bowel  into  the  wound,  and  open  it  soon  after,  giving  free  vent  to  the 
gases. 

Patients  under  these  circumstances  will  rarely  stand  much  surgery,  and 
if  a  more  extensive  operation  is  required  to  effect  a  closure,  if  the  tissues 
around  the  wound  are  necrotic,  or  if  there  is  much  gaseous  distention  and 
peritoneal  inflammation,  the  best  plan  of  treatment  is  that  which  will  save 
life,  irrespective  of  the  sequela?.  A  method  practised  by  I!.  II.  Follis  of  the 
Johns  Hopkins  Hospital,  which  bids  fair  to  be  of  great  value  in  the  most  serious 
cases,  is  thai  of  draining  the  bowel  by  stitching  the  opening  to  the  incision, 
and  letting  the  fecal  discharges  take    place  outside  until   recovery,  when  the 


TREATMENT.  449 

bowel  may  be  resected  or  anastomosed.  This  plan  of  treatment  has  also  been 
advocated  by  Bland  Sdtton,  and  has  the  approval  as  well  of  E.  \Y. 
Goodall  (Lancet,  May  21,   1S9S,   p.   1402). 

After  extensive  operations  of  this  character,  with  protracted  drainage, 
the  abdominal  wall  is  left  very  thin  at  the  site  of  the  scar,  and  a  hernia  is  almost 
sure  to  occur  after  the  patient  has  been  on  his  feet  and  taking  active  exercise 
for  some  time. 

In  cases  of  operation  for  typhoid  perforation  of  the  ileum,  it  would  be  of 
service  if  surgeons  would  always  note  carefully  the  condition  of  the  appendix 
whenever  it  can  be  done  with  safety. 


29 


CHAPTER  XX. 

APPENDICITIS  IN  THE  CHILD. 

HISTORY.     ETIOLOGY.     SYMPTOMATOLOGY  AND  DIAGNOSIS.     TREATMENT. 

History. — The  earliesl  recorded  case  of  appendicitis  in  t ho  child  is  probably 
that  reported  by  Parkinson  in  1812,  in  a  buy  five  years   old  (sec  Chap.  I, 

p.  3).  Ii.iff,  in  1832,  published  the  case  of  a  boy.  twelve  years  old,  who  died  of 
an  abscess  in  the  right  iliac  fossa,  and  at  the  autopsy  the  appendix  was  found 
to  contain  a  "stone"  |  Land.  .1/"/.  and  Chir.  Jour.,  L832,  vol.  1,  p.  214).  Bohr  in 
1837  (.1/"/.  Zeit.  f.  Heilk.,  1837)  and  Burne  in  1839  {Med.  andChir.  Trans., 
L839,  vol.  L3,  p.  33)  both  reported  cases  in  which  perforations  of  the  appendix 
occurred  in  children  of  ten  and  fourteen  years  old,  respectively.  In  1870,  Betz 
published  a  paper  entitled  "Ileus  in  a  child  seven  months  old,  resulting  from 
perforation  of  the  appendix  and  agglutination  of  the  intestines,"  which  is  the 
first  occasion  on  which  appendicitis  Ln  the  child  receives  separate  attention,  as 
the  earlier  reports  all  treat  of  appendicitis  per  se,  and  mention  its  occurrence  in 
the  child  only  incidentally  (Memorabil.  HeiUcund.,  1870,  Bd.  15,  p.  118).  A  num- 
ber of  other  cases  are  given  in  the  very  complete  bibliography  preceding  G.  K. 
M att k fjstock's  admirable  treatise  in  Gerhardt's  Handbuchder  Kinderkrank- 
heiten,  published  at  Tubingen  in  1880,  which  forms  the  basis  of  all  subsequent 
work  in  this  line.  In  1897  a  paper  of  the  highest  merit  by  F.  Karewski 
appeared. in  the  Dtsch.  medicinische  Wochenschr.,  followed  in  1901  by  an  admir- 
able article  by  F.  Selter  in  the  Arch.  f.  Kinderhettk*  To  these  important 
papers,  together  with  other  scattered  articles  touching  upon  particular  phases 
of  the  subject,  such  as  thai  ofV.  Gibney  in  1891  on  the  diagnosis  between 
coxitis  and  appendicitis,  and  that  of  J.  P.  C.  Griffith  in  1901  on  the 
differential  diagnosis  between  appendicitis  and  pneumonia  in  the  early  stages, 
1  am  indebted  for  many  of  the  facts  here  presented.  Griffith's  article,  in 
particular  (Univ.  /'run.  Butt.,  1901,  No.  8,  p.  300).  contains  one  of  the  most 
satisfactory  cases  of  appendicitis  in  the  child  as  yet  reported,  on  account  of  the 
excellent  clearness  of  the  autopsy  record. 

A  well-nourished  negro  boy,  three  months  old.  began  to  suffer  from  diarrhea 
with  mucus  in  the  stools:  in  twenty-four  hours  the  fecal  discharge  ceased,  although 
some  blood  was  said  to  have  passed,  and  vomiting  with  obstipation  began.     The 

*  An  article  on  appendicitis  in  the  child  was  read  by  A.  McCosh  at  the  meeting  of  the 
American  Medical  Association  in  Atlantic  City,  June  7  to  11,  1904,  aid  appears  in  the  Jmir. 
Med     t     oc  .  Sept.  21.  1904. 

4r,n 


HISTORY.  451 

little  patient  was  admitted  to  the  Children's  Hospital  in  a  state  of  collapse,  with 
a  rapid  weak  pulse,  sunken  eyes,  and  an  abdomen  so  distended  that  palpation 
was  unsatisfactory.  There  were  no  stools  and  no  straining.  Under  the  impres- 
sion that  an  intestinal  obstruction  might  be  present,  large  enemata  were  admin- 
istered, but  only  a  small  quantity  of  mucus  stained  with  reddish  fecal  matter  was 
returned.  The  temperature  ranged  from  102°  F.  to  105.5°  F.  Death  occurred 
five  days  after  the  onset  of  the  illness,  and  the  autopsy  showed  a  general  peritonitis 
caused  by  a  gangrenous  appendix  6  cm.  long.  Its  proximal  portion  was  healthy 
and  comparatively  immovable,  while  the  distal  half,  which  was  without  a  mesen- 
tery, was  freely  movable.  About  the  middle  of  the  organ,  separating  the  sound 
from  the  diseased  portion,  there  was  a  constriction,  characterized  microscopic- 
ally by  a  large  increase  of  connective  tissue  and  the  abrupt  disappearance  of  the 
mucosa,  presenting  evidence  of  a  chronic  inflammation,  associated  with  the  pres- 
ence of  newly  organized  blood-vessels.  A  little  beyond  the  constriction,  and  at 
the  beginning  of  the  gangrenous  area,  the  appendix  was  crossed  by  a  band  of 
lymph,  evidently  of  recent  formation  and  not  tightly  adherent  to  it,  which 
stretched  from  the  mesentery  of  the  ileum  to  the  peritoneal  coat  of  the  bowel. 
The  end  of  the  appendix  was  blackish  in  color,  and  within  it  there  was  tremen- 
dous congestion,  extravasation  of  blood,  and  a  complete  degeneration  of  the  epi- 
thelial cells  with  a  granular  detritus  remaining  to  show  the  former  localization  of 
the  tubules.  It  seems  probable  that  this  condition  was  caused  by  a  kinking  of 
the  appendix  occasioned  by  the  shortness  of  its  mesentery  and  by  the  fixation 
of  its  proximal  half,  associated  with  the  free  movability  of  its  distal  end.  No  con- 
cretions nor  other  foreign  bodies  were  present. 

Anatomy. — In  the  chapter  on  anatomy  it  was  shown  that  the  appendix 
develops  by  a  process  of  narrowing  down  of  the  embryonic  cecal  pouch;  and 
the  section  on  "Differentiation"  exhibits  a  series  on  appendices  of  all  sizes  up 
to  the  adult  stage  (Chap.  IV,  Figs.  28,  29,  30,  31).  While  primary  differentiation 
between  the  cecum  and  the  appendix  takes  place  at  the  eight  w  e eks  s  t  a  g e 
(intrauterine),  the  secondary  differentiation  occurs  at  birth.  It 
manifests  itself  in  a  dilatation  of  the  proximal  pouch,  giving  rise  to  the  formation 
of  cecal  sacculations.  The  appendix,  owing  to  this  cecal  enlargement,  now 
appears  relatively  narrow,  and  lies  coiled  up  in  the  iliac  fossa  beneath  the 
cecum,  while,  as  the  lumbar  region  is  relatively  shorter  in  the  child,  the  cecum 
lies  at  a  comparatively  higher  level.  Moreover,  the  iliac  fossa  is  less  capacious 
in  the  infant  than  in  the  adult,  so  that  the  entire  ileocecal  apparatus  appears 
at  a  somewhat  higher  level  than  McBurney's  point. 

The  permanent  position  of  the  appendix  in  relation  to  the  ileocecal  appa- 
ratus is  determined  previous  to  birth,  the  only  subsequent  change  being  a  slight 
sagging  out  of  the  anterior  pouch  or  pouches  of  the  cecum  to  till  the  growing 
iliac  fossa.  This  explains  the  more  retrocecal  position  of  the  appendix  in  the 
adult  as  compared  with  the  child.  The  usual  fusion  of  the  mesocolon  and  the 
attachment  of  the  mesappendix  to  the  posterior  wall  take  place  long  before 
birth,  and  at  this  time  the  position,  direction,  amount  of  fixation,  and  degree 


452 


APPENDICITIS    IN    THE    child. 


of  mobility  of  the  appendix  have  all  been  determined  and  undergo  no  further 
change.  Abnormal  positions  of  the  entire  ileocecal  region  due  to  arrested  devel- 
opment are  not  infrequent  in  children,  hut  as  these  malformations  persist  into 
adult  life,  and  are  not  a  Special  characteristic  of  the  infantile  type,  they  cannot 
be  specially  considered  here. 

As  for  the  appendix  itself,  the  differences  between  the  infantile  type  and  the 
adult  form  lie  in  the  relative  size  of  the  appendix,  the  thickness  of  the  coats, 
and  the  form  of  the  ceco-appendical  junction.  Compared  with  the  adult  form, 
the  infantile  appendix  is  slightly  larger  in  relation  to  the  size  of  the  body,  and 
considerably  larger,  if  it  is  considered  in  relation  to  the 
entire  alimentary  canal  (see  Chaps.  IV  and  V.  sections 
on  "  Differentiation "  and  "Dimensions").  The  coats  of 
the  infantile  appendix  are  much  more  delicate  in  propor- 
tion, especially  the  submucous  coat  :  the  ceco-appendical 
junction  is  occasionally  funnel-shaped,  especially  if  the 
cecum  and  the  appendix  are  in  direct  linear  continuity. 
It  is  stated  that  the  funnel-shaped  entrance  facilitates 
the  entrance  of  foreign  bodies,  but  it  is  probable  that 
it  renders  expulsion  equally  easy  (see  Fig.  235).  The 
valves  of  the  infantile  appendix,  if  present,  do  not  seem 
to  close  the  mouth  of  the  organ  as  readily  as  do  those 
of  the  adult.  The  reason  for  this  lies  in  the  relatively 
greater  lumen  and  smoother  mucosa  of  the  infantile 
appendix,  as  compared  with  the  narrower  lumen  and 
corrugated  mucosa  at  the appendico-cecal  junction  in  the 
adult. 

Age. — Determination  of  the  earliest  age  at  which 
appendicitis  has  been  known  to  occur  in  the  child  has 
been  a  matter  of  frequent  investigation,  as  well  as  the 
relative  frequency  of  its  occurrence  in  the  child  as  com- 
pared with  the  adult.  Anions  the  most  valuable  con- 
tributions to  this  phase  of  the  subject  are  a  thesis  by 
.Miss  Gordon  (L'appendicite  chen  /'  enfant,  Thesede  Paris, 
1896);  an  article  by  P.  Ski.TEH,  already  mentioned  (Die 
Perityphlitis  des  Kindes,  Arch.  Kinderheilk.,  101)1,  Bd.  31,  p.  59);  and  another 
by  T.  H.  Maxlf.y  (Jour.  Amer.  Med.  Assoc.,  June,  1901).  Miss  Gordon  shows 
that  for  a  period  of  twelve  years  antedating  Ins;!.  26  cases  of  appendicitis  were 
found  among  nearly  50,000  sick  children,  while  during  a  period  of  three  years 
between  1893  and  1896,  SO  cases  were  collected,  although  the  number  of  children 
was  decidedly  smaller.  Selter,  reckoning  from  Matterstock's  statistics,  and 
allowing  at  the  same  time  for  the  relative  frequency  of  children  and  young 
adults  in  the  hospital  wards,  found  that  appendicitis  was  seven  times  more  fre- 
quent before  the  age  of  fifteen  than  it  was  from  fifteen  to  thirty.     He  makes  the 


Conor. 


FlO.     235.         FUNNEL-BHAPED 

t  'mi  ici     a)  in  a  C \-i 

mi      \.    r     i   i     PERFOS  MIM. 

Appendicitis  in  a  Girl 
I  tut  i  vmi  One-half 
\  ears  i >i  \'.i  'I  rom 
tii<  Surgical  Depart 
ment.  Johns  Hopkins 
Hospital,  Oct.  31, 
1903  ' 

Note  the  large  opening 
in  the  gangrenous  appen- 
dix choked  by  -a  fecal  con- 
cretion i.l    M    T.  i  inney). 


ETIOLOGY.  453 

same  computation  from  Sonnenburg's  statistics.  Manley  shows  that  appen- 
dicitis is  extremely  rare  under  the  age  of  five,  but  that  it  increases  in  frequency 
after  that  age,  occurring  nearly  as  often  between  the  ages  of  ten  and  fifteen  as 
later  in  life. 

Griffith,  in  his  admirable  essay  already  mentioned,  treating  of  appendicitis 
in  children  of  two  years  old  and  under,  gives  fifteen  cases  within  that  limit. 
The  earliest  case  at  the  time  he  wrote  was  six  weeks;  since  then,  however,  a 
case  has  been  reported  by  A.  Gloniger  of  Lebanon,  Pa.,  in  which  a  male 
child  was  delivered  in  a  normal  labor  by  J.  Harris  of  Jonestown,  who  was  about 
to  ligate  the  cord  when  he  noticed  an  enlargement  at  its  base,  in  which,  upon 
viewing  it  by  transmitted  light,  a  coil  of  intestine  could  he  distinctly  seen. 
Twelve  hours  later  the  case  was  seen  by  Gloniger,  who  found  the  tumor 
increased  in  size;  and  as  other  means  of  relief  proved  ineffectual,  he  operated 
the  next  morning  under  ether  anesthesia,  when  the  baby  was  only  forty-one 
hours  old.  The  sac  was  opened  throughout  its  entire  length,  and  the  greater 
part  of  the  small  intestine,  with  the  cecum,  and  the  transverse  colon  were 
found  within  it.  The  appendix,  which  was  about  an  inch  in  length,  stood 
up  straight  and  stiff,  and  showed  unmistakable  signs  of  inflammation.  The  in- 
testines were  firmly  adherent  to  the  sac  and  were  liberated  with  difficulty.  Upon 
enlarging  the  umbilical  ring,  the  relief  from  strangulation  was  at  once  apparent 
by  the  restoration  of  the  normal  color.  The  appendix,  which  had  no  mesen- 
tery, was  excised,  and  the  wound  thus  made  closed  with  a  suture  of  fine  catgut. 
The  hernial  sac  was  cut  away,  and  the  peritoneum  closed  with  catgut.  The 
umbilical  vessels  were  then  ligated  and  some  troublesome  oozing  from  the  skin 
was  controlled  by  coapting  the  skin  surfaces  by  means  of  Thiery's  clamps.  The 
child  made  an  excellent  recovery. 

ETIOLOGY. 

The  causes  operating  to  produce  appendicitis  in  a  child  are  much  the  same  as 
those  acting  in  adults.  The  reason  why  infancy  and  early  childhood  are  com- 
paratively exempt  lies  in  the  fact  that  the  h  a  r  d  f  e  c  a  1  c  o  n  c  r  e  t  i  o  n  s 
so  often  met  with  in  appendicitis  take  some  time  to  form,  and  are,  therefore, 
rarely  found  during  the  first  years  of  life;  an  additional  reason  is  that  an 
infant  spends  most  of  its  life  lying  down;  and,  fur- 
thermore, trauma,  which  is  the  most  frequent  exciting  cause  in  older 
children  (see  Chap.  XVI),  is  practically  absent  during  infancy. 

The  great  liability  of  the  male  sex  to  disease  of  the  appendix  is  as  conspicu- 
ous in  childhood  as  in  later  life.  According  to  Manley's  statistics,  the  propor- 
tion of  boys  to  girls  is  as  two-thirds;  according  to  other  observers,  it  is  as  follows; 

Males.  1  I  M  U.ES. 

Jalaguier 112  70 

Matterstnck 21  51 

Jacob 21  8 


I.M  APPENDICITIS    IN    THE    CHILD. 

Errors  in  did  are  frequently  noted  in  the  histories  of  children,  especially 
in  the  recurrent  form.  The  relationship  between  appendicitis  and  infectious 
diseases  has  been  fully  dwell  upon  (see  Chap.  XV]  I.  It  must  always  be  remem- 
bered thai  in  children  the  acute  exanthemata  may  be  ushered  in  by  misleading 
symptoms  of  appendicitis. 

Foreign  bodies  and  concretions  arc  mel  with  in  children  from  five  years  old 
and  upward  about  as  frequently  as  in  adults;  it  is  a  matter  of  surprise,  however, 
to  find  a  foreign  bodypresenl  in  a  little  child,  and  even  in  an  infant  bui  a  lew 
weeks  old.  In  Betz's  case  already  mentioned,  a  child  seven  months  old  had 
a  perforated  appendix  covered  with  a  diphtheritic  exudate,  inside  which  were 
three  fecal  concretions  as  large  as  hempseeds,  yellowish-white  in  color,  easily 
broken,  and  showing  the  usual  concentric  arrangement.  In  another  case  orig- 
inally reported  by  Demme,  and  cited  by  Fenger  in  the  Cyclopedia  for  Children's 
Diseases,  a  child  of  seven  weeks,  fed  entirely  upon  porridge  since  it  was  a  week 
old,  was  taken  ill  at  the  beginning  of  its  seventh  week  with  high  fever,  tympanites, 
and  tenderness  in  the  cecal  region,  followed  by  peritonitis  and  death.  The  autopsy 
revealed  a  diffuse  peritonitis,  and  an  appendix  dilated  and  filled  with  firm  concre- 
tions, which  the  microscope  showed  were  nothing  more  than  conglomerate  masses 
of  undigested  porridge;  there  was  no  perforation  of  the  appendix. 

There  is  undoubtedly  an  etiologic  relation  between  intestinal  worms  and 
some  forms  of  appendicitis.  Metchnikoff  (Semaine  ///<'</..  1901,  No.  11)  and 
Genser  (Wien.  med.  Wochenschr.,  L901,  No.  9)  have  called  attention  to  the 
frequency  with  which  a  s  c  a  r  ides  have  been  found  under  varying  conditions. 
I  have  myself  given  several  such  instances,  accompanied  by  illustrations  (see 

("hap.  XVI  ).      In  oi f  these,  a  woman,  operated  upon  in   my  clinic,  a  segmeni 

of  a  tapeworm  was  found. 

In  several  instances  children  with  symptoms  of  appendicitis  have  been 
Entirely  relieved  by  santonin.  Arbore-Rally  {Arch,  de  mid.  des  enfants, 
1900}  relates  such  a  case  in  a  hoy.  ten  years  old,  suffering  with  excessive  consti- 
pation ;  two  surgeons  made  a  diagnosis  of  general  peritonitis,  hut  on  account  of 
his  had  general  condition  did  not  operate.  On  the  fifth  day  of  his  illness  he 
vomited  a  living  a  scar  is  ;  three  days  later,  after  the  administration  of  san- 
tonin, a  second  worm  2">  cm.  long  was  passed,  and  after  large  evacuations  he 
recovered.  Metchnikoff  cites  three  cases  showing  distinct  symptoms  of 
appendicitis  in  which  the  patients,  one  of  them  a  child  twelve  years  old,  were 
relieved  by  anthelmintic  treatment,  without  operation.  In  each  instance  the 
eggs  of  both  a  s  c  ar  is  and  trie  h  o  C  e  p  h  al  us  were  found  in  the  stools. 
He  justly  lays  stress  upon  the  necessity  for  a  microscopic  examination  of  the 
stools  for  ova  in  all  cases  in  which  there  is  any  room  for  suspicion,  a  measure 
especially  important  in  children,  in  whom  a  slight  intra-abdominal  source  of 
irritation  may  provoke  violent  symptoms  with  fever.  The  r61e  of  the  worms 
may  he  to  produce  an  erosion  of  the  mucosa,  and  so  open  the  way  for  the 
invasion  of  bacteria;  it  may  he  that  an  inoculation  takes  place  with  the  act  of 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  455 

exciting  the  lesions.  The  trichocephalus  found  in  the  cecum  produces  lesions  by 
its  habit  of  boring  inward  and  imbedding  the  anterior  end  of  the  body  beneath 
the  mucosa. 

Still  (Brit.  Med.  Jour.,  April  15,  1899)  looks  upon  the  oxyuris  ver- 
micular is  (pin-worm)  as  the  cause  of  catarrhal  troubles  in  the  appendix. 
Moty  [Semaine  med.,  1901,  Nos.  11-14)  found  oxyuris  in  three  out  of  five  cases 
recently  under  his  care.  He  insists  that  an  immediate  examination  of  the 
appendix  after  removal  is  necessary  to  discover  the  worms.  A  case  of  this 
kind  which  occurred  in  the  practice  of  my  colleague.  J.  C.  Bloodgood,  has  been 
already  cited  (see  Chap.  XVI,  p.  377). 

The  activity  of  children  in  running  about  and  playing  especially  exposes 
them  to  trauma,  in  the  blows,  falls,  and  violent  exertion  which  are  the 
familiar,  hourly  events  of  childhood.  The  effort,  for  example,  of  skipping 
rope  backward  many  times  in  succession  has  Keen  reported  as  causing  a  rapidly 
fatal  appendicitis  with  perforation  of  the  appendix,  which  contained  a  con- 
cretion. 

Several  observers  have  commented  upon  a  supposed  connection  between 
appendicitis  and  the  uric  acid  diathesis  in  children.  Sutherland  in  an  article 
on  this  subject  (Brit.  Med.  Jour.,  1892,  vol.  1,  p.  856)  bases  his  theory  on  the 
anatomic  similarity  between  the  appendix  and  the  tonsils,  which  are  so  often 
affected  in  gout,  both  organs  being  largely  composed  of  adenoid  tissue,  a  theory 
first  brought  forward  by  Bland-Sutton,  who  also  lays  stress  upon  the  patho- 
logic resemblance  between  simple  and  suppurative  appendicitis  and  the 
analogous  condition  of  the  tonsils. 


SYMPTOMATOLOGY  AND  DIAGNOSIS. 

The  differences  which  appear  in  appendicitis  in  the  child  and  the  adult 
assume  the  utmost  importance  upon  the  clinical  side.  There  is  a  general  consen- 
sus of  opinion  that  the  symptoms  in  childhood  are  often  extremely  vague,  and 
lack  the  pointed  precision  of  the  adult  form,  which  so  frequently  forces  the 
diagnosis  even  upon  the  lay  mind. 

The  abdomen  of  a  little  child  is  but  a  miniature  of  the  adult  in  the 
relative  approximation  of  all  the  organs,  and  in  the  close  contiguity  of 
those  in  the  pelvis  and  in  the  upper  abdomen.  Pari  passu  with  age  and 
the  assumption  of  the  adult  form,  the  oi<_ran<  are  separated  by  a  wider  in- 
terval, their  differentiation  being  thus  facilitated.  With  the  earlier  age.  and 
the  approximation  of  the  boundary  lines  of  the  abdomen,  we  have  also 
incapacity  for  fixed  attention  while  describing  subjective  conditions;  lack 
of  appreciation  as  to  the  value  of  questions  and  vagueness  of  expression  in 
answering  them;  together  with  impatience  under  examination,  especially  when 
painful.  As  it  is  often  impossible  to  elicit  a  clear  statement  as  to  the  exact 
seat  of  pain,  the  surgeon  must  depend  greatly   upon   palpation,   watching  the 


456  Al'l'l auk  ins    in   THE   CHILD. 

fare  of  the  child  at  the  same  time,  while  the  attention  is  diverted  during 
the  process.  In  examining  an  ill-trained  child,  or  one  under  the  age  of  ten 
years,  the  services  of  a  specialist  skilled  in  children's  diseases  are  (if  the  utmost 
value,  as  he,  from  force  of  babil  and  long  experience,  will  better  understand  the 
child  nature  and  inure  readily  elicit  a  response;  hi'  is  also  better  fitted  to  estimate 
the  value  of  symptoms  under  circumstances  which  would  only  confuse  an 
ordinary  observer.  'While  there  are  these  disadvantages,  there  is,  fortunately, 
the  counter-advantage  that  an  anesthetic  (chloroform)  is  easily  administered 
in  children,  affording  a  good  opportunity  to  examine  the  iliac  region  through 
the  thin  relaxed  abdominal  wall. 

A  n  e  x a m i n a  t  i o  n  1>  y  t  h  e  r e c t  u  m  should  n  ev  er  be 
n  e  g  led  e  d  ,  since  the  adult  finger  reaches  higher  in  the  infantile  pelvis  than 
in  that  of  the  adult,  so  that  the  suspected  area  is  more  easily  touched.  KarEWSKI 
and  Selteb  have  shown  that  in  almost  every  case  in  which  the  disease  has 
advanced  beyond  the  appendix,  the  extension  takes  place  along  the  right  pelvic 
wall,  where  the  inflammatory  masses  can  be  easily  felt.  In  28  cases  of  appen- 
dicitis in  children  given  by  Selter,  6  had  a  general  peritonitis  and  11  a  circum- 
scribed abscess;  oul  of  the  11  cases  of  abscess,  suppuration  in  all  but  one 
extended  down  into  the  right  lesser  pelvis,  and  in  2  of  these  10,  the  abscess 
had  traveled  across  the  rectum  and  formed  a  mass  on  the  left  side,  above 
Poupart's  ligament.  In  one  instance  it  was  noted  that  the  abscess  lay  on 
the  left  side  and  had  no  connection  with  the  cecum,  hut  at  the  operation, 
when  an  incision  was  made  in  the  left  groin,  a  tubular  abscess  channel  the 
width  of  two  thumbs  was  found  extending  down  into,  and  across  the  pelvis, 
in  front  of  the  rectum,  and  up  over  the  right  pelvic  wall. 

Carron  de  la  Carriere  has  put  on  record  1  cases  of  recurrent  appendic- 
itis in  children,  manifested  by  vomiting  alone,  abdominal  symptoms  and 
fever  being  entirely  lacking.  Frtjitnight  believes  that  there  is  often  "in 
children  a  prodromal  stage,  lasting  weeks  or  even  months,  before  conclusive 
signs  are  developed  by  which  a  diagnosis  can  be  arrived  at."  (Arch.  Pediat., 
1891,  vol.  8,  p.  937.)  Among  the  premonitory  symptoms,  he  mentions  interfer- 
ence with  walking  and  standing,  with  tingling  in  the  right  leg. 

Mahechal  (XIII  Coiii/.  Intern.  mid.  <i  chir.,  Paris,  1900,  p.  644)  reports  the 
case  of  a  little  girl,  eight  years  old.  who  had  an  acute  appendicitis  characterized 
by  entire  absence  of  fever,  a  quiet  pulse,  and  no  vomiting.  There  was  no  tender- 
ness at  McBurney's  point,  neither  was  there  resistance,  fluctuation,  nor  infiltra- 
tion. The  patient  complained  vaguely  of  pain  in  the  right  side  of  the  abdomen, 
which,  however,  was  not  aggravated  on  palpation;  her  expression  was  slightly 
distressed,  but  she  was  not  prostrated.  At  the  end  of  four  days  the  pain  was  more 
marked,  there  was  some  diarrhea,  the  countenance  was  pinched  and  she  appeared 
prostrated;  at  the  same  time  a  slight  sense  of  resistance  over  the  abdomen  became 
perceptible,  with  a  little  dulness  on  percussion.  A  diagnosis  of  appendicitis  was 
made,  and  operation  performed   four  days    after  the  patient  came    under  obser- 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  457 

vation;    the    appendix    was    a    little    violaceous    in    color,  but    not    perforated, 

although  its  extremity  was  bathed  in  pus,  which  also  filled  the  pelvis.  In  spite  of 
evacuation,  drainage,  and  removal  of  the  appendix,  death  took  place  in  twelve 
hours. 

No  examination  of  a  child  with  a  suspected  appendicitis  is  complete  which 
does  not  include  an  investigation  of  the  thoracic  viscera;  often  the  first  sign 
of  a  pneumonia  or  pleurisy  or  even  of  a  bronchitis  (Richardson)  is  a  right  iliac 
pain,  liable  to  be  mistaken  for  an  appendicitis.  The  least  sign  of  disturbance 
in  another  organ  in  a  doubtful  case  should  command  the  examiner's  attention, 
and  such  a  clue,  if  followed  up,  will  in  some  instances  lead  to  a  correct  solution 
of  a  puzzling  problem.  It  is  absolutely  necessary  that  the  medical  attendant 
should  approach  the  bedside  with  calm  undisturbed  judgment,  forewarned 
and  on  his  guard  against  the  public  attitude  of  expectation,  which  is  ready  at 
once  to  count  every  obscure  abdominal  pain  the  sign  of  an  appendicitis  and 
the  forerunner  of  an  operation. 

Kabewski  has  laid  special  stress  upon  the  fact  that  most  cases  of  appen- 
dicitis in  children  are  preceded  by  many  attacks  of  gastro-intestinal  disorder, 
with  more  or  less  pain  and  diarrhea,  or  constipation,  together  with  nausea  and 
vomiting.  As  these  attacks  often  occur  in  association  with  an  overloaded 
stomach,  attention  is  almost  sure  to  be  directed  to  the  digestion  in  the  early 
days  of  illness.  Where  a  child  has  repeated  attacks  of  colic  and  intestinal 
disturbance,  especially  if  any  tenderness  is  found  on  the  right  side  of  the 
abdomen,  appendicitis  should  be  suspected  until  the  contrary  is  proved.  A 
common  preliminary  sign  is  the  desire  to  empty  the  bladder  frequently, 
associated  with  pain  in  doing  so.  Appendicitis  in  a  child  is  easily  mistaken  for  a 
digestive  disturbance,  from  the  mild  and  transient  character  of  the  initial 
symptoms,  the  discomforts,  the  abdominal  pains,  and  the  constipation.  In 
treating  constipation  in  a  child  there  should  always  be  positive  assurance 
that  there  is  no  appendicitis  behind  it;  in  doubtful  cases  it  would  be  far  wiser 
to  treat  constipation  with  opium  than  with  castor  oil.  In  all  c  a  s  e  - 
where  the  diagnosis  is  not  clear,  it  is  wiser  to  put 
the  child  to  bed  and  watch  for  a  few  days,  than 
to  risk  the  accidents  of  an  extension  while  the  child  is  going  to  school  or 
romping  with  other  children.  Selter.  in  11,000  cases  of  children's  affections, 
observed  27  of  appendicitis,  including  some  very  mild  cases.  He  insists  that 
many  cases  are  lost  through  a  false  diagnosis  of  digestive  disturbance  such 
as  colic  or  intestinal  catarrh,  and  cites  his  personal  experience  as  an  example. 
Up  to  the  age  of  fourteen,  he  suffered  year  after  year  from  attack-  >>\  pain  in 
the  ileocecal  region,  with  nausea,  quickened  pulse,  anxiety,  and  sweatings, 
associated  alternately  with  diarrhea  or  constipation.  The  diagnosis  at  the 
time  was  "intestinal  c  a  t  a  r  r  h  "  or  "typhlitis  stercor- 
alis."  After  he  was  fourteen  he  had  no  more  attacks.  He  insists  that 
in    the  intestinal  catarrh  associated  with  colicky  pains,  of  both  nursing  chil- 


458  \i-i'i:\ni<  l  i  I-    in    THE    CHILD. 

(hen  and  those  of  riper  years,  an  unusual  tenderness  in  the  region  of  the  cecum 
is  often  revealed  by  examination,  and  his  conclusion  is  to  the  effecl  that 
ndicularis"  is  common  in  children. 
The  tendency  to  a  1  a  r  v  a  i  e  I  o  r  m  of  appendicitis  in  children, 
together  with  the  obscurity  which  may  attend  it.  is  well  shown  by  two  cases 
in  young  girls,  patients  of  E.  A.  Cushing  of  Cleveland,  Ohio. 

In  line-  the  child,  going  regularly  to  school,  attended  as  usual  cm  the  morn- 
ing of  the  day  on  which  Cushing  first  saw  her.  She  had  had  no  pain,  nor  evident 
fever,  had  no1  been  at  any  time  confined  to  bed,  and  there  was  no  history  of  pre- 
vious attacks  of  colic.  The  services  of  a  physician  were  sough!  simplj  because 
she  looked  white,  felt  languid,  and  had  do  appetite.  There  was  no  reason  for  sus- 
pecting any  particular  organ,  but  as  a  routine  matter  an  examination  of  the  entire 
body  was  made,  when  a  well-defined  mass  was  discovered  in  the  rijdit  iliac  fossa. 
Dudlei  Ai  i.i  n  operated  the  next  morning,  < >j >< -niiiii:  an  abscess,  and  removing 
an  appendix  which  was  on  the  point  of  perforation.  In  the  second  case,  a  irirl 
seven  years  old  was  seen  on  the  second  day  of  an  attack  of  what  was  supposed  by 
her  watchful  mother  to  be  indigestion,  because  of  epigastric  pain,  nausea,  and 
constipation.  Her  temperature  was  100  1'..  her  pulse  SO.  and  her  expression 
bright.  '  Operation  on  the  same  day,  by  Allen,  disclosed  an  abscess  and  an  appendix 
near  perforation. 

While  making  his  abdominal  examination  the  surgeon  must  hear  in  mind 
that  the  adhesions  in  a  child  may  be  ext  remely  delicate,  and  more  than  ordinary 
care  must  lie  exercised  in  order  to  avoid  any  risk  nf  rupturing  thorn.  II.  Gage 
Bo,  i.  l/<  </.  and  Surg.  Jour.,  May  2  I.  189 1 1  mentions  a  case  in  which  the  adhesions 
amund  a  localized  abscess  in  a  child  were  ruptured  during  sleep,  and  another  in 
a  young  adult,  where  rupture  took  place  during  an  effort  at  stool.  In  both  in- 
stances the  disappearance  of  symptoms  was  accompanied  by  collapse,  a  rapidly 
progressing  genera]  peritonitis,  and  death.  A  movable  kidney  ought  not  to  he 
mistaken  for  a  diseased  appendix  from  the  very  fact  of  itsmobility.  A  congen- 
ially misplaced  kidney,  however,  lying  in  the  right  iliac  fossa,  might  easily 
he  so  mi-taken,  if  the  simple  discovery  of  a  mass  were  taken  a-  decisive. 

It  must  always  he  remembered  that  in  children,  the  early  symptoms  of  appen- 
dicitis are  apt  to  he  those  associated  with  motion.  A.  WoRCESTEB  of  YVal- 
t ham.  Mass.  (Bost.  Med.  and  Surg.  Jour.,  Aug.  4,  1892),  relates  a  case  in  which 
a  hoy.  ten  years  of  age,  with  an  indefinite  history  of  three  week-'  illness 
presenting  undefined  symptoms,  was  sent  at  the  end  of  that  time  to  consult  a 
physician;  he  entered  the  office  with  a  marked  stoop,  and  a  limp  so  pronounced 
that  he  could  not  stand  upright.  A  diagnosis  of  appendicitis  was  made,  and  on 
operation  a  good-sized  abscess  of  the  "larvate"  form  was  discovered.  An- 
other case  of  the  same  kind  occurred  in  the  practice  of  Pi.  I).  Freeman  of 
South  Orange,  X.J.  While  calling  professionally  upon  another  member  of  the 
family,  he  noticed  a  little  girl,  eleven  years  old,  limping  as  she  played  tennis  in 
the  yard  close  by,  and  standing  in  a  position  similar  to  that  of  hip  disease. 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  459 

On  inquiry  it  was  found  that  she  had  complained  for  a  few  days  of  indefinite 
pains  in  the  lower  part  of  the  abdomen,  and  on  calling  her  into  the  house 
and  examining  her.  a  tender  fluctuating  mass  was  found  in  the  right  iliac  re- 
gion; the  right  leg  was  flexed  and  adducted,  there  was  muscular  rigidity  over 
the  lower  abdomen,  and  considerable  pain  on  pressure  over  and  around  the 
mass;  the  rectal  temperature  was  103°  F.  and  the  pulse  90.  She  had  had  no 
considerable  pain  at  any  time,  and  no  chill.  At  the  operation,  performed  at 
midnight  of  the  same  day,  a  large  abscess  surrounding  the  appendix  was 
evacuated  and  the  remains  of  a  sloughing  appendix  removed. 

In  several  instances  it  has  happened  that  a  pleural  empyema  has 
been  discovered  and  operated  upon,  while  the  primary  cause,  a  suppurating 
appendix,  has  not  been  discovered  until  the  postmortem.  It  behooves  the 
operator,  therefore,  in  every  case  of  empyema,  particularly  in  right-sided 
affections,  and  above  all  when  the  pus  is  ill-smelling,  to  bear  in  mind  this 
possibility,  and  to  make  such  examinations  of  the  right  iliac  fossa  (rectal  above 
all!)  as  shall  decide  this  question. 

Without  doubt,  says  Karewski,  many  of  the  puzzling  cases  of  a  puffed- 
out  umbilicus  and  abscess  at  this  point,  followed  by  fistula,  are  due  to  lesions 
of  the  appendix.  In  a  few  instances  the  diagnosis  has  declared  itself  in  the 
appearance  of  a  small  fecal  calculus  at  the  umbilicus. 

Appendicitis  in  the  child  may  be  mistaken  for:  Acute  indiges- 
tion; typhoid  fever;  ileus;  pneumoni  a  o  r  pleurisy; 
tubercular  peritonitis;  intussusception;  hip  disease; 
hernia;     ovarian      disease. 

Acute  Indigestion. — AVe  have  here,  it  may  be,  the  history  of  an  indis- 
cretion in  diet,  vomiting,  and  pain,  the  latter  probably  generalized  in  character 
without  any  special  localized  tenderness  in  the  iliac  fossa.  There  is  fever  in  both 
cases,  but  that  of  the  indigestion  is  more  sthenic  in  character,  and  there  is  no 
progressive  increase  in  the  leucocytes  as  counted  from  hour  to  hour;  in  indiges- 
tion the  attack  is  sudden  in  its  onset,  with  intense  pain  from  the  first,  associ- 
ated with  much  restlessness,  and  the  symptoms  disappear  quickly  with  a 
thorough  evacuation  of  the  bowels  and  a  restricted  diet. 

Typhoid  Fever. — This  disease  is  slower  in  its  prodromata  than  appendicitis, 
creeping  up  day  by  day  to  its  crisis  while  appendicitis  develops  much  more 
quickly  and  with  more  definitely  localized  symptoms.  I  know  of  no  case  as 
yet  in  which  an  appendicitis  has  apparently  arisen  in  the  course  of  typhoid 
fever  in  a  child  to  confuse  the  medical  attendant.  The  profounder  and  more 
striking  signs  of  appendicitis  will  usually  prevent  any  confusion.  The  Widal 
reaction  becomes  the  important  diagnostic  criterion  in  the  later  stages. 

Ileus. — Appendicitis  in  its  earlier  stages  may  be  mistaken  for  ileus,  begin- 
ning, as  the  latter  often  does,  with  obstinate  constipation,  vomiting,  and  other 
evidence  of  a  profound  systemic  disturbance,  without  fever,  and  with  a 
good    pulse.     In   such    cases    the  closest  attention  must  be    paid  to  the  local 


4f)0  APPENDICITIS    IN    THE    CHILI). 

manifestations,  and  the  counting  of  leucocytes  should  never  be  omitted. 
The  worst  possible  treatment  of  an  appendicitis  is  the  use  of  enemata  to  over- 
come a  suspected  ileus.  Karewski  has  twice  seen  cases  of  diffuse  appendicitis 
which  had  been  treated  for  five  or  six  days  with  high  injections,  and  in  one 
instance  the  castor  oil  thrown  into  the  rectum  was  found  Boating  in  the 
peritonea]  cavity. 

Pneumonia  and  Pleurisy. — Experienced  clinicians  have  repeatedly  noted, 
especially  in  children,  cases  of  intrathoracic  disease,  pneumonia  and  pleurisy, 
in  which  at  the  outset  the  pain  has  been  chiefly  abdominal.  Such  being  the 
fact,  we  cannot  be  too  much  on  our  guard,  when  called  to  a  patient 
manifestly  very  ill,  with  abdominal  pain,  an  elevated  temperature,  fixation  of 
the  diaphragm,  constipation,  drawn-up  knees,  and  perhaps  a  swollen  abdomen, 
against  too  hastily  assuming  the  existence  of  an  appendicitis  and  the  necessity 
for  immediate  operation. 

I  cannot  better  illustrate  these  difficulties  than  by  citing  a  case  published 
by  II.  L.  Barnard  (Lancet,  Aug.  2,  1903),  who  is  indebted  for  it  to  the  rare 
frankness  of   F.  S.    EvE,   the  operating  surgeon. 

The  patient,  a  girl  seventeen  years  old.  had  attended  the  outdoor  clinic  at  the 
London  Hospital  during  some  months  for  gastric  ulcer  with  marked  anemia.  She 
had  once  before  had  an  attack  similar  to  the  one  about  to  he  described.  One  morn- 
ing, in  1899,  she  started  for  work,  as  usual,  and  on  her  way  was  seized  in  the  street 
with  violent  epigastric  pain  and  vomiting.  She  was  brought  to  the  hospital  at  once 
in  a  state  of  collapse,  her  pulse  being  1-0  and  thready,  while  her  temperature  was 
104.5°  I'.  Ih-r  abdomen  was  rigid,  motionless,  distended,  and  very  tender,  these 
sijrns  being  most  marked  in  the  epigastric  region.  She  was  admitted  to  the  sur- 
gical wards  as  a  case  of  perforated  gastric  ulcer,  and  within  two  hours  her  abdomen 
was  opened.  The  anterior  and  posterior  surfaces  of  the  stomach  were  explored 
as  well  as  the  greater  and  lesser  curvatures,  hut  no  trace  of  gastric  ulcer  was  found, 
nor  was  there  any  peritonitis.  Unfortunately  ether  was  the  anesthetic  given, 
and  her  cough  became  so  violent  that  a  coil  of  intestine  and  some  omentum  escaped 
between  the  stitches,  requiring  to  he  washed  and  returned,  after  which  the  ab- 
domen was  again  sewed  up.  <  >n  the  second  day  after  admission  it  became  clear 
that  she  had  right  basal  pneumonia,  hut  her  temperature  had  fallen  to  101°  F. 
<>n  the  third  day  it  rose  again  to  104°  I'..  signs  of  consolidation  appeared  at  the 
left  base,  and  she  died  on  the  fifth  day  from  the  commencement  of  the  attack. 
At  the  postmortem  examination  double  basal  pneumonia  and  right  diaphrag- 
matic pleurisy  were  found,  while  in  the  stomach  was  a  shallow  ulcer  the  size  of 
a  sixpenny  piece,  which  was  not  near  perforation.     There  was  no  peritonitis. 

J.  P.  C.  Griffith,  in  an  article  entitled  "Pneumonia  mid  pleurisy  in  early 
life  simulating  appendicitis"  (Jour.  Amer.  Mul.  Assoc,  Aug.  29,  1902),  presents 
the  dangers  of  an  error  in  diagnosis  in  a  most  convincing  manner,  and  1  quote 
one  clear  case  from  this  source. 

"  K.  S..  male,  seven  years  old.  admitted  to  the  Children's  Hospital   Novem- 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  461 

ber  2.  1899.  under  the  can'  of  II.  R.  Wharton.  He  had  had  at  various  times 
more  or  less  abdominal  pain,  which  was  never  severe  until  three  weeks  previously, 
when  lie  had  a  typical  attack  of  appendicitis,  as  regarded  by  the  physicians  in 
charge  of  him.  The  symptoms  at  the  time  consisted  of  severe  pain  and  tender- 
ness in  the  right  side  of  the  abdomen,  especially  at  McBurney's  point,  fever,  con- 
stipation, and  restlessness.  He  recovered  partially,  but  the  tenderness  is  said 
to  have  remained.  <  >n  October  30th,  three  days  before  admission,  he  had  had 
a  recurrence  of  pain,  and  again  on  November  1st.  There  had  been  no  vomiting 
at  any  time,  lever  was  said  to  have  persisted  since  the  attack  three  weeks  before. 
On  admission  the  temperature  was  103°  F.,  the  respiration  varying  from  32  to  80, 
and  the  pulse  from  132  to  196.  The  abdomen  was  distended,  tender,  and  some- 
what rigid.  These  symptoms  were  especially  marked  on  the  right  side.  There 
was  also  bronchial  respiration  over  the  entire  lower  lobe  of  the  left  lung.  The 
attending  physician  had  in  person  taken  the  child  to  the  hospital  in  order  to  have 
an  operation  for  appendicitis  performed.  On  refusal  by  the  surgeon  to  do  this. 
he  became  very  angry,  disputed  the  diagnosis  of  pneumonia,  said  he  had  broughl 
the  child  for  the  sake  of  operation  solely,  and  would  remove  him  if  it  was  not  per- 
formed, and  used  other  language  more  forceful  than  polite.  He  was  requested 
to  go  to  the  ward  to  examine  the  patient  himself  again.  This  he  did — and  then, 
apologized.  By  the  evening  of  the  same  day  the  temperature  had  fallen  to  99.2°  V. 
No  further  abdominal  symptoms  were  recorded,  and  the  pneumonic  consolidation 
rapidly  disappeared." 

Out  of  8  cases  given  by  Griffith,  it  is  noticeable  that,  while  severe 
abdominal  pain,  tenderness,  and  distention,  were  prominent  in  all,  cough  was 
so  slight  as  to  attract  the  attention  of  only  the  most  watchful  eye.  A  little 
girl,  eight  years  old,  had  such  intense  abdominal  pain  and  tenderness  that  the 
resident  physician  feared  arsenic  poisoning.  Another  child,  four  years  old, 
hail  obstinate  abdominal  pain,  tenderness  in  the  right  iliac  fossa,  and  distention, 
so  that  the  physician  who  first  saw  the  case  made  the  diagnosis  of  appendicitis. 
but  the  child  was  admitted  to  the  medical  wards,  because  operation  was  for- 
bidden by  the  parents.  When  first  seen  by  Dr.  Griffith,  "except  for  a  few  cos 
rales,  nothing  could  be  detected  on  examining  the  lungs  in  front.  Owing  to 
the  great  distress  of  the  child,  and  because  the  diagnosis  of  appendicitis  seemed 
so  positive,  the  posterior  part  of  the  chest  was  not  examined  on  this  date.  On  the 
next  day  pneumonic  consolidation  of  the  left  lung  was  easily  found.  The  abdom- 
inal symptoms  remained  unchanged."  On  the  following  day  all  the  abdominal 
symptoms  hail  disappeared,  and  the  crisis  occurred  two  days  later. 

J.  L.  Morse  of  Boston  has  given  us  a  picture  of  such  cases,  so  complete 
and  clear  that  nothing  is  wanting  (Ann.  Gyn.  and  Ped..  1900.  vol.  13.  p.  113). 
and  he  warns  us  that  "the  abdomen  has  been  twice  opened  in  children 
by  well-known  Boston  surgeons  for  appendicitis,  when  the  trouble  was  lobar 
pneumonia."  His  first  case  presents  a  typical  picture  of  the  shifting  character 
of  the  signs  of  pneumonia,  from  the  first  abdominal  symptoms  to  the  final 
unmistakable  thoracic  one. 


162  APPENDICITIS    l\"    THE    CHILD. 

The  little  patient,  who  was  seven  years  old,  and  in  perfecl  health,  was  struck 
in  the  abdomen,  during  recess  at  school,  by  one  of  1 1 is  playmates.  Shortly 
afterwards  he  became  faint  and  nauseated,  and  was  sent  home  by  his  teacher. 
He  continued  to  vomil  for  twenty-four  hours,  and  on  the  day  following  the  injury 
he  complained  of  headache,  nausea,  and  pain  in  the  abdomen,  the  bowels  not  hav- 
ing moved.  There  had  been  qo  cough  nor  sure  throat,  and  the  temperature  and 
pulse  wen  Imt  moderately  elevated,  with  no  special  disturbance  of  respiration. 
There  was  a  little  abdominal  tenderness  and  slight  distention,  bu1  a  routine  ex- 
amination of  the  lungs  proved  negative.  <  >n  the  second  day  the  bowels  con- 
tinued closed,  in  spite  of  calomel  and  salt^;  there  was  considerable  abdominal 
distention  and  increased  tenderness,  mure  marked  in  the  right  iliac  fossa,  where 
there  was  slight  dulness;  hut  no  tumor.  The  temperature  was  now  high,  and 
the  pulse  and  respiration  rapid,  but,  although  there  was  a  constant  hacking  and 
evidently  painful  cough,  examination  of  the  lungs  was  again  negative,  so  thai  the 
trouble,  which  seemed  abdominal,  was  considered  as  probably  appendicitis,  and 
as  the  increased  respiration  and  cough  appeared  secondary  to  the  abdominal  dis- 
turbance, but  little  attention  was  paid  to  them.  More  salts  were  ordered  and 
tin'  abdomen  was  poulticed!  During  the  third  nighl  there  were  four  movements 
of    the    bowels,    after   which    the   abdominal    distention    diminished,    and    then-    was 

very  little  tenderness,  hut  the  cough  became  more  troublesome,  and  the  child  com- 
plained of  pain  in  the  righl  lower  chest  and  the  umbilicus,  the  respiration  being 
now  65  and  painful.  An  examination  of  the  lungs  now  showed  marked  dulness, 
with  bronchial  respirations  and  a  few  high-pitched  rales  over  the  right  lower  lobe. 
The  diagnosis  of  lobar  pneumonia  with  reflex  abdominal  symptoms  was  then  made. 
The  next  day  the  abdominal  distention  was  nearly  gone,  and  during  the  succeed- 
ing twenty-four  hour-  even  the  slight  tenderness  disappeared. 

Morse  remarks  that  "eases  of  pneumonia  in  children  beginning  with 
symptoms  pointing  to  the  abdomen,  while  not  common,  are  nevertheless  not 
very  unusual.  The  predominance  of  the  abdominal  symptoms  may,  how- 
ever, lead  to  serious  errors  in  diagnosis These  eases  are  probably 

most  often  overlooked  because  the  possibility  of  their  occurrence  is  not  borne 
in  mind  and  the  examination  of  the  chest  is  neglected.  As  is  shown  by  the 
cases  detailed  above,  however,  the  physical  signs  of  pneumonia  may  not  be 
recognizable  for  several  days.  Yet  even  in  the  absence  of  physical  sipns  the 
combination  of  symptoms  is  usually  such  .as  to  justify  a  probable  diagnosis  of 
pneumonia.  An  acute  onset  with  high  temperature  is  always  suggestive  of 
pneumonia.  If  in  addition  to  the  acute  onset  and  hisrh  temperature  the  rapid- 
ity of  die  respiration  is  increased  out  of  proportion  to  that  of  the  pulse,  the 
combination  is  almost  pathognomonic  of  pneumonia.  This  is  true  even  in  the 
absence  of  cough.  Too  much  importance  can  hardly  he  attached  to  this  combi- 
nation of  temperature,  pulse,  and  respiration  in  diagnosis,  and  many  errors  may 
lie  avoided  by  keeping  it  constantly  in  mind.  When  it  is  present,  vomiting, 
abdominal  pain,  constipation,  and  even  distention  and  tenderness,  may  usually 
he  regarded  as  symptoms  of  secondary  importance,  probably  reflex  in  origin." 


SYMPTOMATOLOGY    AXD    DIAGNOSIS.  403 

It  is  evident  from  a  consideration  of  these,  as  well  as  of  other  important 
eases,  that,  as  Richardson  says,  "in  acute  right-sided  diseases  of  the  thorax, 

the  symptoms  of  appendicitis  may  be  so  easily  simulated  that  a  surgeon  may  he 
completely  deceived. " 

The  differential  diagnosis  musl  depend  upon  attention  to  the  following 
factors,  commonly  present  in  intrathoracic  disease:  li  A  sudden  rise  of  tem- 
perature, and  persistent  high  temperature,  without,  as  a  rule,  corresponding 
increase  in  the  pulse-rate.  (2)  Full  and  sthenic  character  of  the  pulse.  ;; 
Disappearance  of  the  fixation  of  the  abdominal  muscles  with  each  respiration. 
(4)  Superficial  character  of  the  tenderness,  which  is  probably  due  to  a  neuritis 
affecting  one  of  the  lower  intercostal  nerves,  and  disappears  under  firm  pressure 
with  the  whole  hand.  (5)  Rapidity  of  the  respiration,  which  should  always 
excite  attention,  and  call  for  closer  attention  to  the  chest. 

In  addition,  great  caution  should  be  displayed  in  regard  to  the  follow- 
ing points:  Close  attention  should  be  given  to  any  cough.  Examination  for 
thoracic  disease  should  he  made  in  every  case  of  suspected  appendicitis  in  a 
child.  In  cases  of  reasonable  doubt  it  is  better  to  wait,  and  watch  for  more 
definite  local  symptoms,  either  in  the  chest  or  in  the  abdomen,  before  assum- 
ing the  responsibility  of  operating.  Fewer  lives,  I  think,  will  be  sacrificed  by 
such  a  policy  than  by  a  hasty  interference  instituted  because  there  is  a 
possibility  of  disease  in  the  appendix. 

Tubercular  Peritonitis. — In  the  absence  of  any  other  known  focus  of 
tuberculosis,  an  attack  of  acute  tuberculosis  accompanied  by  pain,  together 
with  some  swelling  and  resistance  localized  in  the  right  iliac  fossa  and  associated 
with  marked  fever,  may  present  insuperable  diagnostic  difficulties  until  the 
disease  has  progressed  into  the  chronic  stage. 

Karewski  has  reported  an  interesting  case  of  tubercular  peritonitis  origi- 
nating in  the  appendix. 

A  child,  two  years  old,  had  an  abdominal  tumor  situated  below  the  navel  ami 
extending  both  to  the  ri<dit  and  to  the  left,  the  swelling  having  formed  first  upon 
the  right  side.  The  child  came  from  tuberculous  parents,  and  had  had  swollen 
glands  from  its  infancy;  it  was  emaciated,  very  tympanitic,  and  had  been  ill  for 
a  long  time.  There  was  diarrhea  alternating  with  constipation,  and  attacks  of 
ileus.  An  incision  revealed  cheesy  pus,  and  a  vermiform  appendix  perforated 
at  its  extremity,  where  there  was  a  small  abscess.  The  child  died  in  twenty  days, 
and  at  the  autopsy  the  cecum  was  found  covered  with  tuberculous  ulcerations, 
extending  into  the  appendix.  There  was  no  tuberculosis  in  any  other  part  of  the 
intestinal  tract  and  the  general  peritoneal  cavity  was  walled  off. 

In  a  second  case  a  boy,  five  years  old,  had  hail  an  attack  of  appendicitis  a  year 
before  coming  under  observation,  a  little  hard  lump  remaining  in  the  neighbor- 
hood of  the  appendix.  After  several  months  he  began  to  limp,  and  to  keep  the 
right  leg  constantly  flexed.  Hip-joint  disease  was  suspected,  and  on  this  account 
he  was  brought  to  the  surgeon,  who  found  a  contracture  of  the  ileopsoas  muscle, 


464  APPENDICITIS    IN   THE    CHILD. 

due  to  the  remains  of  the  perityphlitic  exudate  An  operation  was  refused.  The 
tubercular  character  of  the  disease  seemed  probable  on  accounl  of  an  old  bony 
focus  below  the  knee-joint.  A  large  tumor  soon  began  to  form  in  the  righl 
lower  abdomen,  with  free  ascites.  At  a  subsequenl  operation  a  cheesy  abscess 
ound  surrounding  the  extremely  hardened  and  thickened  appendix. 

M.  II.  Richardson,  speaking  from  his  own  experience,  says:  "A  tumor  at 
the  ileocecal  valve  was  in  one  case  supposed  to  be  appendicular.  It  proved  t<> 
be  an  acute  tuberculosis  of  the  mesenteric  glands  of  the  mesocolon.  A  dissec- 
tion carried  thoroughly  as  far  as  the  receptaculum  chyli  was  permanently 
curative."     (Bost.  Med.  and  Sum.  Jour..  July  14.  1898.) 

Manley  in  speaking  of  such  eases  says:  "H  is  quite  impossible  to  affirm 
whether  or  not  the  appendix  is  involved.  Under  these  circumstances,  I  have 
often  seen  an  operation  undertaken  for  appendicitis  reveal  do  lesion  of  the  organ  " 

(IOC.    ril.i. 

In  making  a  differential  diagnosis  between  tubercular  appendicitis  and  appen- 
dicitis arising  from  other  causes,  it  must  be  borne  in  mind  thai  tubercular  ap- 
pendicitis tends  to  run  a  protracted  course,  and  the  patienl  seems  more  tolerant 
of  an  accumulation  in  the  iliac  fossa  than  he  would  be  with  abscess  due  to  any 
other  cause.  There  is  often  an  ileopsoas  contraction  accompanied  by  a  ten- 
dency to  limp,  and  emaciation  increases  as  the  disease  progresses.  The  his- 
tory of  the  parents,  and  also  of  the  locality  and  the  house  in  which  the  patient 
lives,  are  of  importance;  the  early  history  of  the  child  itself  musl  also  be 
investigated,  especially  as  to  the  former  presence  of  enlarged  glands,  or  of  cheesy 
troubles  in  or  near  the  joints.  Finally,  whenever  a  case  of  appendicitis  runs 
an  obscure  course,  tuberculosis  should  be  suspected. 

Intussusception. — Intussusception  of  the  vermiform  appendix  is  a  rare  affec- 
tion, limited,  as  a  rule,  to  childhood;  I  have  found  but  one  case  occurring  in 
an  adult,  and  that  was  in  a  woman  forty  years  of  age.  I  have  collected  and 
analyzed  !!!  cases  of  this  condition  in  children,  and  I  find  that  the  average  age  is 
four  years  and  eight  months,  the  oldest  in  my  list  being  nine  years  and 
the  youngest  thirteen  months.  In  regard  to  sex,  there  were  II  males  and  7 
females,  the  sex  in  one  not  being  stated. 

These  cases  of  intussusception  maybe  divided  into  three  groups: 

1.  Those  in  which  the  vermiform  appendix  is  simply  carried  along  with  the 
intussuscepl  utn  in  an  incidental  manner:  that  is  to  say,  in  which  the  appendix  is 
compelled  to  travel  with  the intussuscepted  colon  simply  because  it  is  organically 
connected  with  it. 

2.  Those  in  which  the  base  of  the  appendix  itself  forms  the  apex  of  the  intus- 
susceptum;  that  is  to  say,  cases  in  which  the  intussusceptum  starts  at  this 
point  of  the  colon. 

3.  Those  in  which  there  is  an  inversion  of  the  appendix,  partial  or  complete, 
with  or  without  inversion  of  the  cecum,  colon,  or  ileum. 


SYMPTOMATOLOGY    AXD    DIAGNOSIS.  405 

The  clinical  picture  of  such  an  ailment  is  that  of  a  chronic  affection  charac- 
terized by  abdominal  pain,  sudden  severe  attacks  of  colic,  doubling  the  child 
over,  and  a  diarrhea  with  blood  and  mucus  in  the  stools.  After  such  an  attack,  the 
child  may  show  improvement,  play,  and  go  to  school,  until  there  is  a  recur- 
rence. There  is  usually,  however,  a  gradual  loss  of  health  and  some  emacia- 
tion. I  have  found  but  one  case  in  which  the  temperature  was  elevated;  and 
the  pulse  is  not  quickened  in  the  intervals.  An  extraordinary  case  in  which 
pain  was  the  one  symptom  is  that  of  McKidd  {Edin.  Med.  Jour.,  18.59,  vol.  11, 
p.  763) : 

1.  A  boy,  seven  years  old.  suffered  for  several  weeks  with  abdominal  pain 
localized  about  one  inch  below  the  umbilicus;  at  the  end  of  this  time  the  pain  be- 
came so  excruciating  that  it  was  necessary  to  keep  the  child  under  the  influence 
of  chloroform  on  account  of  the  distress  occasioned  to  the  neighbors  by  his  con- 
stant screaming.  There  was  no  tenderness  or  swelling  in  the  abdomen,  nor  any 
symptoms  besides  the  pain  at  any  time.  The  bowels  were  somewhat  constipated, 
but  responded  to  purgatives,  and  the  stools  were  normal  in  appearance.  At  the 
autopsy  a  hard  mass  was  found  in  the  cecal  region  which  was  at  first  thought  to 
lie  impacted  feces,  but  on  opening  the  colon  it  proved  to  be  the  invaginated  appen- 
dix, projecting  into  the  lumen  of  the  intestine,  its  base  being  just  over  the  valve, 
so  as  to  "act  as  a  barrier  to  the  proper  exercise  of  its  function  and  obstruct  the 
passage  of  excrementitious  matters  from  the  ileum."  There  was.  properly  speak- 
ing, no  caput  ceci,  and  what  trace  of  it  seemed  to  exist  was  invaginated  with  the 
appendix,  which  was  spiral  in  form,  acutely  inflamed,  and  gangrenous  in  parts. 

In  examining  the  abdomen  there  is  no  marked  tympany  or  localized  tender- 
ness. A  peculiar,  elongate  tumor,  sometimes  sausage-shaped,  occasionally 
more  or  less  globular,  is  found,  most  frequently  in  the  left  flank,  but  sometimes 
in  the  region  of  the  transverse  colon,  or  in  the  neighborhood  of  the  umbilicus. 
In  several  instances  a  second  swelling  has  been  noted.  Such  a  tumor,  when 
carefully  examined,  and  its  position  and  dimensions  noted,  is  apt  at  a  later 
examination  to  appear  different  in  size  and  position.  It  is  often  extremely 
movable  upon  manipulation,  owing  to  a  long  mesocecum.  A  case  in  which 
two  intussusceptions  were  found  in  the  same  patient  is  given  by  W.  H.  \\  atkr- 
hotjse  (Trans.  Path.  Soc.  Lond.,  1898,  vol.  49): 

2.  A  little  girl,  four  years  old,  was  sent  to  the  Victoria  Hospital  for  Children, 
with  a  diagnosis  of  intussusception.  Five  days  before,  the  child  had  been  examined 
under  chloroform,  and  a  tumor  found  in  the  right  side  of  the  abdomen,  which  sul>- 
sequently  disappeared.  When  admitted  to  the  hospital,  the  tumor  reappeared, 
accompanied  by  pain  and  vomiting  in  an  aggravated  form.  <  hi  attempting  to 
reduce  the  tumor  by  enemata,  the  second  enema  returned  blood-stained.  Opera- 
tion was  then  performed,  and  an  intussusception  found,  four  feet  above  the  ileo- 
cecal valve,  which  was  easily  reduced:  but  as  it  was  lying  transversely,  it  was  ob- 
viously not  the  tumor  previously  felt  on  the  right  side.  A  second  intussusception 
of  the  ileocecal  variety  was  then  discovered  and  reduced  with  difficulty  bit  by  bit; 

30 


166  APPENDIl  ins    l\    THE    CHILD. 

when  this  was  effected,  however,  ii  was  plain  that  the  cecum  contained  a  firm  glob- 
ular body  about  one  inch  in  diameter,  while  only  one-half  of  the  vermiform  ap- 
pendix \\a>  visible  externally.  On  investigation  the  globular  body  proved  to  be 
directly  continuous  with  the  mass  in  the  cecum.  While  attempting  to  reduce 
the  inverted  appendix  the  tumid  wall  of  the  cecum  gave  waj  and  the  partially 
gangrenous  appendix  was  seen  in  the  interior.  The  cecum  was  then  excised,  and 
the  ileum  and  ascending  colon  anastomosed  by  means  of  a  .Murphy's  button.  The 
child  never  recovered  from  the  collapse,  and  died  in  about  thirty  hours.  The 
excised  parts  showed  the  invaginated  portion  of  the  appendix  on  the  inner  sidi 
of  the  cecum  as  a  globular  mass,  three-fourths  of  an  inch  long,  and  one-eighth  of 
an  inch  in  circumference  at  the  widest  part;  with  a  somewhal  constricted  neck, 
one  and  three-fourths  inches  in  circumference.  The  portion  of  the  appendix  out- 
side the  cecum  was  five-eighths  of  an  inch  long.  Neither  by  traction  from  with- 
out nor  l>v  pressure  from  within  could  the  intussusception  lie  reduced. 

If  tlie  intussusception  is  extensive,  the  bowel  may  lie  seen  protruding  at 
tlie  anal  orifice.  A  rectal  examination  should  never  lie  omitted,  as  the  soft 
polyp-like  mass  may  he  found  just  within  the  anus,  or  within  reach  of  the  finger. 
it  greatly  facilitates  the  examination  in  these  little  patients,  to  give  enough 
chloroform  to  produce  complete  relaxation. 

A  remarkable  instance,  similar  to  that  of  McKlDD  just  cited,  in  which  no 
tumor  could  lie  detected,  was  a  little  patient  of  T.  A.  Met  I  raw  (Brit.  Med. 
Jour.,  L897,  vol.  2,  p.  956): 

.'!.  A  little  boy,  two  years  old,  had  an  attack  of  cholera  morbus  in  which  the 
stools  were  occasionally  streaked  with  blood.  After  apparently  complete  recovery, 
he  began  to  have  attacks  of  excruciating  pain  in  tlie  abdomen,  which  yielded  only 

to  large  doses  of  opium,  and  these  were  followed  by  slight  amounts  of  blood  and 
mucus  in  the  stools.  As  the  intervals  between  these  attacks  decreased  in  length, 
he  lost  flesh  and  strength,  until  his  condition  became  so  bail  that  an  abdominal 
section  was  advised  to  discover  their  cause.  During  the  paroxysms  of  pain,  the 
abdominal  muscles  would  contract  and  become  hard  and  tense,  hut  there  was  no 
fixation  in  the  intervals,  nor  could  any  tumor  be  fell  in  the  iliac  fossa'  nor  in  the 
rectum;  the  child  referred  the  pain  to  the  epigastrium.  The  temperature  was 
normal  until  the  day  before  the  operation,  when  it  was  11)0°  ]•'.  Intussusception 
was  considered  out  of  the  question,  because  there  was  no  obstruction  and  scarcely 
any  disturbance  of  digestion,  and  a  chronic  appendicitis  was  excluded  on  account 
of  the  normal  temperature  and  absence  of  tenderness  in  the  iliac  fossa.  The  most 
plausible  theory  was  that  of  omental  hernia,  either  in  the  median  line  above  the 
navel,  or  within  the  abdomen  through  some  pathological  aperture.  A  median 
incision  was  made  above  the  umbilicus,  when  the  transverse  colon  pre- 
sented itself,  intensely  inflamed,  and  coated  with  lymph.  On  pulling  this  out.,  it 
proved  that  the  ascending  colon  had  a  mesentery  of  such  enormous  length  that 
it  could  be  drawn,  together  with  the  cecum,  through  the  incision  above  the  navel. 
The  whole  of  the  large  intestine  was  greatly  inflamed.  The  cecum,  which  was 
of  the  fetal  variety,  was  unusually  long;    its  end.  with  the  appendix,  was  invagi- 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  407 

nated  inside  the  bowel,  and  could  be  felt  through  its  walls.  The  intussusception 
involved  the  cecum   and   the  appendix   only.     The   invaginated   structures   were 

excised  just  at  the  point  where  infolding  occurred,  the  opening  closed,  and  the 
whole  covered  by  catgut  sutures.  The  child  made  a  rapid  recovery,  retarded  only 
by   a   stitch    abscess. 

The  etiology  will  vary  with  the  starting-point  of  the  inversion.  A  predis- 
posing factor  is  a  long  mesocecum.  Any  inflammatory  process  in  the  head 
of  the  cecum  causing  a  localized  thickening  of  its  walls,  or  an  inflammatory 
condition  around  the  orifice  of  the  appendix,  causing  it  to  pout  out  into  the 
lumen  of  the  cecum,  would  offer  a  convenient  grip  for  the  circular  muscles  of 
the  bowel  to  catch  and  exercise  propulsive  force  in  the  direction  of  the  current. 
A  tumor  at  or  near  the  base  of  the  appendix,  if  there  was  a  loose  mesocecum, 
would  seem  to  offer  a  most  favorable  opportunity  for  the  inversion  of  the 
cecum  with  the  appendix,  but  no  case  of  this  kind  has  yet  been  reported. 

It  is  not  so  difficult  to  understand  how  an  inflammatory  process  involving 
the  proximal  process  of  the  appendix  might  cause,  at  first  a  swelling,  and  then 
a  pouting  of  its  mucosa  into  the  cecum,  when  the  swollen  edematous  tissue 
with  its  strangulated  veins  would  serve  to  draw  the  remainder  of  the  mucosa 
onward,  step  by  step,  until  the  entire  organ  was  inverted. 

In  the  following  case,  given  by  K.  Montsekrat,  the  writer  says  positively 
that  the  point  of  origin  was  at  the  base  of  the  appendix  (Liverpool  Med.  and 
Chir.  Jour.,  1901,  vol.  21,  p.  08): 

4.  A  boy,  four  years  old,  was  admitted  to  the  Children's  Infirmary  with  parox- 
ysmal pain  in  the  right  side  of  the  abdomen,  which  had  persisted  for  a  month, 
lasting  a  day  or  two  at  a  time,  and  then  disappearing  for  an  interval  of  varying 
duration.  A  mass  could  be  plainly  felt  extending  across  the  abdomen  from  the 
right  loin  to  the  splenic  region,  freely  movable,  and  not  tender.  The  bowels  were 
somewhat  relaxed,  and  two  days  after  admission,  the  administration  of  an  enema 
was  followed  by  stools  containing  mucus  and  blood.  The  swelling  could  be  re- 
duced towards  the  right,  but  did  not  disappear  entirely;  it  varied  in  size  from 
day  to  day.  On  operation,  an  incision  was  made  at  the  outer  border  of  the  right 
rectus  and  on  a  level  with  the  umbilicus,  and  it  was  then  seen  that  there  was  an 
intussusception  of  the  cecum  into  the  colon,  carrying  with  it  the  ileocecal  valve 
and  the  terminal  portion  of  the  ileum.  This  was  easily  reduced  down  to  the  last 
knuckle,  which  consisted  of  the  vermiform  appendix  and  a  part  of  the  cecal  wall, 
the  base  of  the  appendix  being  invaginated  into  the  cecum,  until  only  about  one- 
eighth  of  an  inch  of  its  tip  was  visible.  There  were  no  adhesions,  but  the  peri- 
toneal surface  of  the  appendix  and  the  cecum  were  so  hard  and  indurated  that  it 
was  with  difficulty  the  invagination  could  be  turned  out  by  using  both  thumbs 
in  making  steady  pressure  on  the  mass  in  the  cecum.  The  appendix  was  then 
amputated  at  the  base;    the  child  made  an  uneventful  recovery. 

When  the  appendix  becomes  more  or  less  inverted  into  the  cecum,  it  may  then 
act  as  a  polypoid  tumor  within  the  bowel  and  give  rise  to  further  invagination. 


468  APPENDICITIS    IN    THE    CHILD. 

The  following  case,  given  by  <  !onnob,  is  one  in  which  a  blow  on  the  abdomen 
is  supposed  to  have  given  rise  to  the  invagination  I  Lam;  /,  l'.tn:;.  vol.  2.  p.  tiooi : 

5.  A  boy,  nine  years  old,  was  admitted  into  St.  Bartholomew's  Hospital  with 
abdominal  pain,  stating  thai  about  a  month  previouslj  he  had  received  a  blow 
on  the  abdomen,  alter  which  he  vomited  and  was  ill  in  bed  for  lour  days.  On 
getting  up,  he  was  much  constipated,  and  the  abdominal  pain  continued  at  inter- 
vals.   On  admission,  he  seemed  to  be  in  g I  general  condition,  his  temperature 

was  99.2°  1'..  both  knees  were  drawn  up,  and  the  abdomen  was  rigid,  the  rigbl 
rectus  especially  standing  out.  There  was  no  abdominal  dulness,  bul  some  ten- 
derness and  an  ill-defined  resistance  in  the  right  iliac  Fossa.  A  rectal  examina- 
tion was  negative.  The  case  was  supposed  to  lie  one  of  subacute  appendicitis 
or  of  tuberculous  disease.  He  improved  under  treatment,  and  was  discharged 
in  two  week-,  quite  well  except  for  some  thickening  in  the  righl  iliac  fossa.  For 
a  week  he  did  well,  when  he  was  seized  with  abdominal  pain,  followed  by  vomiting, 
and  was  again  brought  to  the  hospital.  <  hi  examination,  the  abdomen  was  found 
slightly  iiiri<  1 .  and  an  oval  swelling  was  apparent  jusl  above  the  umbilicus,  moving 
with  respiration;  this  was  firm,  tender,  and  freely  movable  towards  the  right  iliac 
fossa,  lh'  passed  two  drachms  of  brighl  red  1>1 1  from  the  bowels.  On  opera- 
tion, an  intussusception  was  found  at  the  level  of  the  umbilicus,  the  apex  of  which 
could  he  felt  as  a  smooth  hard  mass  within.  The  bulk  of  the  intussusception  con- 
sisted of  the  ileum,  and  was  easily  reduced  until  the  cecum  was  reached,  when  it 
was  found  that  the  hard  mass  felt  within  was  inside  the  cecum,  its  base  being  marked 
by  a  dimple  on  the  internal  aspeel  of  the  cecum  and  surrounded  by  adhesions. 
This  proved  to  he  a  completely  inverted  appendix,  with  it.-  mesentery  drawn  into 
the  dimpled  area.  All  attempt,  at  reduction  were  futile  and  the  appendix  was 
removed  in  one  mass  with  the  caput  ceci.  and  the  opening  closed  by  sutures.  No 
mention  is  made  of  drainage. 

The  title  of  this  paper  is  "Intussusception  of  the  vermiform  appendix,"  hut 
from  the  description  of  the  case  and  the  accompanying  diagram,  it  appeared 
to  me  to  be  one  of  complete  inversion  of  the  appendix.  On  referring  the  matter 
to  Connor,  he  writes  me  as  follows:   "The  appendix  was  completely  intussus- 

cepted  in  the  true  sense  of  the  word.     By  this  I  mean  that  the  appendix  was 

ipletely  thrust  into  the  cecum,  'inverted'  on  itself  like  the  linger  of  a  glove: 

thus,  when  excised,  the  relative  positions  of  the  peritoneal  and  mucous  coats 
were  reversed.  The  contiguous  part  of  the  cecum  was  slightly  pulled  in,  form- 
ing a  dimpling  at  the  basal  attachment  of  the  appendix.  This  evidently  was 
the  first  step,  and  was  followed  by  a  large  intussusception,  with  the  tip  of  the 
inverted  appendix  as  the  summit  of  the  intussusceptum ;  the  cecum  and  ileum 
being  in  turn  drawn  into  the  ascending  and  transverse  colon.  The  diagram 
in  my  article  exactly  reproduces  the  condition  found,  when  all  but  the  appendix 
itself  was  reduced.  The  part  excised  is  now  in  the  St.  Bartholomew's  Museum. " 
IIaesler  (Archiv  f.klin.  Chir.,  1002,  Bd.  36,  p.  817,  Case  9)  cites  a  case 
which  shows  several  stages  of  invagination  quite  clearly: 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  4G9 

6.  A  boy,  nine  years  old,  was  attacked  with  pain  in  the  abdomen,  which  yielded 
at  once  to  cold  applications.  A  week  later  he  had  another  attack,  accompanied 
by  vomiting,  after  which  the  attacks  became  more  and  more  frequent,  until  in 
four  and  a  half  months,  when  he  was  admitted  to  the  hospital,  he  was  confined 
to  lied  most  of  the  time  and  was  much  emaciated  from  constant  vomiting.  About 
four  weeks  before  this  date  his  mother  noticed  a  swelling  on  the  left  side  of  the 
abdomen,  which  increased  in  size  during  the  attacks  of  pain,  and  she  stated  that 
for  about  six  months  his  stools  had  contained  large  pieces  of  mucus.  Examina- 
tion showed  a  roundish  abdominal  swelling  the  size  of  a  child's  fist  in  the  left  hypo- 
chondrium,  freely  movable,  and  only  painful  when  compressed.  During  eleven 
days  spent  in  the  hospital,  he  had  several  attacks  of  pain  extending  towards  the 
bladder,  and  large  lumps  of  mucus  appeared  in  the  stools.  A  diagnosis  of  intus- 
susception was  made,  and  on  operation  the  tumor  was  found  in  the  right  hypo- 
chondrium;  it  was  easily  lifted  out  of  the  peritoneal  cavity  by  reason  of  the  ex- 
tremely long  mesentery,  when  it  was  seen  that  the  cecum,  together  with  the  ap- 
pendix, was  chronically  inflamed,  and  invaginated  with  the  lower  ileum  into  the 
ascending  colon.  All  attempts  at  reduction  were  futile,  and  the  invaginated  parts 
were,  therefore,  resected,  the  colon  being  divided  three  finger-!  >readt lis  beyond  the 
tumor.  An  iodoform  gauze  drain  was  inserted.  A  good  recovery  followed.  The 
specimen  showed  various  stages  of  invagination,  and  it  could  be  plainly  seen  that 
the  primary  one  was  that  of  the  cecum  and  appendix.  The  invaginated  appendix 
lay  free  in  the  lumen,  and  its  base  was  gangrenous  at  the  point  of  reflection. 

In  one  of  my  collected  cases  a  probable  appendicitis  is  cited  as  the  supposed 
cause  of  the  intussusception,  but  it  is  certain  that  if  the  appendix  had  been  pre- 
viously inflamed,  its  walls  thickened,  or  bound  down,  an  inversion  could  not 
occur. 

If  the  colon  enters  the  intussuscipiens,  the  appendix  of  course  goes  with  it. 
The  invagination  of  the  appendix  with  the  colon  may  then  be  inferred  in  all 
such  cases.  The  inversion  of  the  appendix,  more  or  less  complete,  may  be  sus- 
pected when  the  invagination  is  reduced  down  to  a  small  hard  tumor  in  the  right 
iliac  fossa.  On  the  other  hand,  an  appendicitis  in  a  child  has  been  mistaken 
for  an  intussusception.  (Jkiffith  gives  two  such  cases  in  his  series  of  15 
occurring  in  children  of  two  years  and  under. 

The  question  of  carcinoma  in  the  differential  diagnosis  is  raised  by  the  fol- 
lowing case,  the  only  one  reported  of  intussusception  in  an  adult.  The  operation 
was  done  with  the  expectation  of  finding  a  malignant  affection,  and  even  when 
the  abdomen  was  opened,  it  was  not  possible  at  first  to  get  a  clear  idea  of 
the  nature  of  the  disease: 

7.  (Haksi.kh,  he.  n't..  Case  9.)  A  woman,  forty-two  years  old,  who  had  always 
had  good  health,  fell  from  an  electric  car.  receiving  a  blow  on  the  head,  after 
which  she  was  ill  in  bed  for  some  time,  suffering  from  sleeplessness  and  severe  vomit- 
ing. One  night  she  had  a  sudden  severe  pain  near  the  navel,  extending  toward 
the  right  iliac  fossa.  No  resistance  was  perceptible  at  first,  but  after  three  weeks 
she  noticed  a  knot  in  her  abdomen  which  was  freelv  movable  and  increased  in  size. 


470  APPENDICITIS    IX   THE    CHILD. 

The  attacks  of  pain  continued  al  intervals  for  six  weeks,  when  she  entered  the 
hospital.  Examination  then  showed  a  smooth  tumor  in  the  righl  iliac  fossa  the 
size  of  a  large  Est;  her  bowels  moved  only  after  medicine,  and  she  was  suffering 
from  meteorism,  nausea,  and  vomiting.  Her  genera)  condition  was  bo  had  and 
was  so  much  emaciated  thai  a  provisional  diagnosis  was  made  of  carcinoma 
of  the  ascending  colon.  On  operation  the  cecum  and  the  vermiform  appendix 
could  not  lic>  Found.  After  separating  adhesions  so  thick  as  to  resemble  a  solid 
tumor,  the  intestine  was  resected  from  10  cm.  above  the  ileum  to  the  hepatic  flexure 

of  the  colon.     The  patient   recovered  and  was  in  g I   health  three  years  alter  the 

ration.  Examination  of  the  resected  portion  of  the  intestine  showed  the  ileum 
passing  directly  into  the  colon,  the  cecum  and  the  appendix  being  apparently  lack- 
ing. <  >n  cutting  into  the  bowel,  the  valve  and  the  invaginated  appendix  could 
be  seen  projecting  into  its  lumen.  The  appendix  was  the  most  prominent  portion. 
so  that  it  seemed  not  unlikely  that  it  was  the  starting-point  of  the  difficulty.  Its 
lumen  contained  a  small  amount  of  local  material. 

Treatment  of  Intussusception. — It  occasionally  happens 
that  nature  herself  will  effect  a  cure  by  a  spontaneous  amputation  of  the 
appendix.  An  excellent  illustration  of  this  is  shown  in  a  case  reported  by 
J.  McFarland  (Proc.  Path.  Soc.  Phila.,  1902,  vol.   1,  p.  163): 

8.  A  little  girl,  eight  years  old,  was  treated  for  an  abdominal  trouble  supposed 
to  be  intussusception.  The  symptoms  relieved  themselves  spontaneously,  and 
during  convalescence  a  mass  of  tissue  was  passed  per  rectum,  after  which  she  made 
a  rapid  and  uneventful  recovery.  The  discharged  mass  consisted  of  two  separate 
fragments,  one  of  which,  about  5  cm.  in  length  and  :!  cm.  in  breadth  resembled 
the  cecum;  the  second  fragment  consisted  of  a  Hat  piece  of  intestine,  the  size  of 
a  half-dollar,  from  which  a  tube  was  given  off,  about  1(1  cm.  long,  "which,"  the 
writer  says,  "was  certainly  the  vermiform  appendix."  The  naked-eye  diagnosis 
was  confirmed  by  microscopic  examination. 

The  following  plans  of  treatment  may  be  employed,  preferably  in  the  order 
given  : 

Palliative,  by  means  of  manipulation,  massage,  enemata,  etc. 

Celiotomy  and  reduction,  by  manipulation,  with  removal  of  the  appendix. 

Celiotomy  and  reduction,  by  opening  the  cecum,  and  effecting  reduction 
by  counter-pressure  from  within,  followed  by  removal  of  the  appendix. 

Amputation  of  the  appendix  and  of  the  adjacent  chronically  inflamed  cecum. 

Amputation  of  the  entire  cecum. 

Amputation  of  the  cecum  and  ileum. 

Amputation  of  cecum,  ileum,  and  colon,  as  far  as  involved. 

The  first  attempts  al  treatment  will  naturally  be  pallia  1  ive  and  di- 
rected toward  ileocolic  intussusception  in  general.  Warm  enemata  of  flax- 
seed tea  may  be  given,  with  the  pelvis  elevated,  and  an  attempt  may  be  made 
under  chloroform  to  reduce  the  tumor.  The  patient  should  then  be  well  ban- 
daged and  kept  on  a  restricted  diet. 


SYMPTOMATOLOGY   AND    DIAGNOSIS.  4d 

"Where  there  remains  a  persistent  tumor,  however  small,  the  intussus- 
ception is  sure  to  recur,  and  the  only  proper  plan  of  treatment  is  that  of  opera- 
tion, by  some  one  of  the  methods  mentioned  above.  Several  eases  in  my 
list  appeared  to  do  well  for  a  time  under  palliative  treatment,  but  a  recurrence 
always  soon  took  place,  making  it  necessary  to  have  recourse  to  surgery.  It 
may  be  laid  down  as  a  rule,  therefore,  if  there  is  a  residual 
mass,  opera  t  e.  The  danger  in  waiting  is  that  of  the  obstruction  to 
the  circulation,  with  the  peritonitis,  and  the  sloughing  which  may  take  place, 
as  in  a  case  of  W.  S.  Colman  (Trans.  ('Int.  Sue.  Lond.,  1898,  vol.  31,  p.  '22'): 

9.  A  boy,  eight  years  old,  was  admitted  to  the  Hospital  for  Sick  Children, 
with  a  history  of  paroxysmal  pains  in  the  lower  abdomen  and  vomiting,  for  fifteen 
weeks  past.  The  bowels  were  open  and  the  stools  normal.  Examination  showed 
a  full  and  somewhat  resistant  abdomen,  with  a  definite  movable  swelling  in  the 
left  flank,  between  the  costal  margin  and  the  iliac  crest,  which  appeared  to  vary 
in  size  even  during  the  examination.  An  hour  later,  after  an  attack  of  pain,  the 
swelling  was  found  considerably  altered  in  size  and  consistence,  having  almost 
reached  the  middle  line  and  become  much  harder;  in  the  course  of  several  days 
it  became  elongate  and  firmer.  Three  weeks  after  admission  the  patient  had  a 
severe  attack  of  pain  with  violent  vomiting.  Two  distinct  tumors  could  then  be 
made  out:  (1)  A  firm,  sausage-shaped  mass  in  the  position  of  the  transverse  colon, 
and  (2)  a  firm,  round  mass  in  the  left  lumbar  region.  The  next  day  the  conditions 
had  again  changed,  and  the  sausage-shaped  swelling  could  no  longer  be  felt.  On 
operation,  the  tumor  m  the  left  hypochondrium  was  easily  recognized  as  an  intus- 
susception in  the  transverse  colon  and  splenic  flexure.  Reduction  was  easy  up 
to  the  last  two  inches  of  the  bowel,  when  it  became  difficult,  and  during  manipu- 
lation the  vermiform  appendix  was  suddenly  extruded,  distal  end  first.  When 
reduction  was  completed,  an  ulcer  the  size  of  a  threepenny  piece  was  found  close 
to  the  juncture  of  the  appendix  with  the  cecum,  extending  through  all  the  coats 
of  the  bowel.  The  ulcer  was  excised  and  the  opening  closed.  I  presume  that  the 
appendix  was  removed  with  the  ulcer  at  its  base,  but  the  writer  does  not  say  so. 
No  drain  was  used.  The  child  did  well  at  first,  but  two  days  after  the  operation 
became  worse,  there  being  much  tenderness  and  resistance  in  the  region  of  the 
cecum.  The  wound  was  then  re-opened  at  its  lower  end,  pus  found,  and  a  drain- 
age-tube inserted,  but  the  child  died  during  the  same  night. 

The  incision  may  be  made  over  the  tumor,  or  in  doubtful  cases  in  the  median 
line,  near  the  umbilicus.  The  appearances  may  then,  at  first  sight,  be  puzzling, 
as  in  the  following  case  of  P.  S.  Haldaxk  (which also  illustrates  oneof  the  phases 
of  invagination)  (Scot.  Med.  and  Chir.  Jour.,  1903,  vol.  12,  p.  33:1): 

10.  A  little  girl,  three  years  old,  was  brought  to  the  Carlisle  Infirmary  suffering 
from  abdominal  discomfort  and  constipation.  There  was  no  history  of  previous 
attacks  of  a  similar  character,  although  the  patient  had  always  required  frequent 

aperients  to  keep  the  bowels  open.     On  examination,  a  rounded,  elastic  swelling 
was  found  near  the  splenic  flexure.     The  child  was  then  removed  from  the  hospital, 


472  APPENDICITIS    IX    THE    CHILD. 

but  when  broughl  back  a  fortnight  later,  ao  oblong  cystic  tumor,  resembling  a 
cystic  kidney,  was  felt  in  the  left  hypochondriac  region,  reaching  down  to  the  um- 
bilicus. '1'his  tumor  disappeared  after  the  administration  of  chloroform,  bul  an- 
other smaller  swelling  of  the  same  kind  was  then  found  at  the  hepatic  flexure  of 
the  colon.  There  was  no  pain  on  examination  and  no  vomiting.  The  following 
night,  after  the  administration  of  an  enema,  there  was  a  severe  attack  of  pain  in 
the  abdomen,  with  accompanying  tenderness  and  rigidity  of  its  walls:  the  patient 
had  several  stools  consisting  of  some  mucus  streaked  with  blood.  Examination 
showed  the  same  swelling  about  and  around  the  umbilicus.  A  diagnosis  of  intus- 
susception was  now  made,  and  on  operation  the  cecum  was  found  distended,  its 
surface  friable,  and  at  the  lower  and  posterior  part  there  was  a  small  projection, 
which  proved  to  be  the  vermiform  appendix,  invaginated  from  runt  to  tip,  the 
root  forming  the  apex  of  the  intussusception.  This  was  reduced  with  difficulty, 
the  invaginated  part  proving  much  swollen  and  deeply  congested,  while  the  part 
at  the  edges  of  the  cecum  was  constricted  and  showed  a  tendency  to  gangrene. 
The  appendix  was  removed  and  the  stump  treated  in  the  usual  way.  It  is  not 
stated  whether  the  patient  recovered. 

Here  the  appendix  was  simply  invaginated  from  root  to  tip  ami  enclosed 
in  the  sheath  of  the  cecum.  If  we  would  divide  these  invaginations  in  which 
the  appendix  forms  the  apex  of  the  contained  bowel  into  groups,  we  might 
classify  them  as  follows: 

1.  Those  in  which  then'  is  a  partial  invagination. 

2.  Those  in  which  there  is  a  complete  invagination  <>(  tic  whole  organ,  as  in 
the  ease  last    cited. 

3.  Those  in  which  there  is  an  invagination  of  the  appendix  with  the  cecum, 
advancing  a  varying  distance  into  the  colon. 

The  simplest  operative  procedure,  ami  that  most  suitable  when  the  appendix 
alone  is  the  peccant  organ,  is  celiotomy  and  reduction  by  manipulation.  The 
intussuscepted  bowel  is  inverted,  squeezing  it  gently  from  above,  while  exer- 
cising traction  from  below,  so  as  to  Wring  the  entire  appendix  into  view,  when 
it  may  he  amputated  and  removed.  Haldane's  case,  just  cited,  is  a  good  illus- 
tration of  this  method,  and  I  give  another  example  in  a  case  reported  by  II.  <i. 
HncvuTH  (Brit.  Med.  Jour..  L893,  vol.  1.  p.  850): 

11.  A  little  girl,  six  years  old.  was  admitted  to  the  Children's  Hospital  in  Not- 
tingham with  a  diagnosis  of  intussusception.  Six  weeks  before  she  had  been  attacked 
by  diarrhea  lasting  a  week,  and  when  this  was  stopped,  abdominal  pain  came  on, 
recurring  every  ten  minutes  day  and  night  up  to  admission.  For  two  weeks  the 
pain  had  been  accompanied  by  vomiting,  but  the  bowels  had  been  normal.  There 
was  considerable  emaciation  and  a  subnormal  temperature.  Examination  of  the 
abdomen  showed  tenderness  on  palpation,  especially  in  the  left  flank;  a  tumor 
could  be  fell  in  the  line  of  the  transverse  colon,  which  passed  down  the  left  flank 
and  ended  in  a  rounded  extremity.  It  could  not  be  determined  with  certainty 
whether  the  horizontal  and  the  vertical  portions  of  the  tumor  were  continuous. 
The  splenic  dulness  was  separated  from  the  tumor  by  a  resonant  area;    the  loin 


SYMPTOMATOLOGY    AXD    DIAGNOSIS.  -ii'.i 

dulness  was  continuous  with  a  dull  note  over  the  tumor.  Diagnosis  was  uncertain 
between  tubercular  peritonitis  of  the  plastic  variety  and  intussusception.  Opera- 
tion showed  a  large  intussusception  of  the  ileocecal  kind,  ending  half-way  down 
the  descending  colon;  this  was  easily  reduced  until  the  end  was  reached,  when  the 
appendix  was  found  invaginated  into  the  cecum.  An  attempt  at  reduction  was 
made  by  pushing  the  appendix  out  from  the  inside  through  the  wall  of  the  cecum, 
without  opening  the  latter,  but  it  was  found  impossible  to  reduce  it  com- 
pletely, as  a  small  portion  of  the  base  was  densely  adherent.  The  appendix  was 
therefore  removed  and  the  wound  stitched  up.  The  child  made  an  uninterrupted 
recovery. 

If  the  bowel  just  above  the  cecum  is  soft  and  pliable,  it  may  be  invaginated 
into  the  cecum,  and  used  in  this  way  to  make  counter-pressure  on  the  appendix, 
while  attempting  its  re-inversion.  Unfortunately,  the  thickening  of  the  sur- 
rounding parts  is  frequently  such  that  the  method  of  reduction  by  manipu- 
lation often  cannot  be  accomplished  without  great  risk  of  rupturing  the 
cecum,  a  thing  which  has  actually  happened  in  one  of  the  cases  already  cited 
(No.  2). 

The  method  of  opening  the  cecum  and  reducing  the  appendix  by  pressure 
from  within  is  well  illustrated  by  the  following  case,  published  by  G.  A.  Wright 
and  K.  Rexshaav  (Brit.  Med.  Jour.,  1S97,  vol.  1,  p.  1470): 

12.  A  boy,  two  and  a  half  years  old,  was  admitted  to  the  Hospital  for  Chil- 
dren with  a  history  of  diarrhea  alternating  with  constipation  for  twelve  months 
previously.  For  some  months  a  slight  protrusion  of  the  anus  had  been  noticed. 
When  first  seen,  he  had  an  attack  of  colic  in  which  both  legs  were  drawn  up,  and 
there  was  increased  resistance  to  the  right  side  of  the  umbilicus,  but  no  tumor. 
The  temperature  was  normal,  the  bowels  constipated.  After  an  attack  of  colic 
and  vomiting  lasting  for  two  days,  a  distinct  tumor  could  be  made  out  above  and 
to  the  right  of  the  umbilicus  and  below  the  liver.  The  child  continued  in  this  state 
for  ten  days,  the  tumor  meanwhile  moving  downward  and  to  the  right,  and  was 
then  sent  to  the  hospital,  where  a  diagnosis  of  intussusception  was  made.  Gurg- 
ling could  sometimes  be  heard  over  the  seat  of  the  tumor,  and  there  was  a  little 
mucus  in  the  stools,  but  no  blood.  I'nder  chloroform,  a  definite  tumor  could  be 
made  out  in  the  course  of  the  transverse  colon,  most  distinct  in  the  left  hypochon- 
drium.  manipulation  of  which  without  an  anesthetic  caused  pain.  The  child's 
condition  grew  worse  for  a  month,  when  an  operation  was  performed.  The  mesen- 
teric glands  were  at  once  noted  as  enlarged,  hardened,  and  apparently  tuberculous, 
but  no  tubercles  were  seen  on  the  peritoneum.  A  hard,  movable  tumor  was  found 
which  slipped  about  in  the  abdomen  from  the  right  iliac  region  to  the  left  side 
of  the  abdomen,  though  only  with  difficulty.  It  was  brought  up  out  of  the  wound, 
when  it  was  found  to  consist  of  the  cecum,  much  thickened,  with  inflammatory 
infiltration,  and  the  adjacent  small  intestine.  The  appendix  was  firmly  tied  down 
by  its  apex  between  the  cecum  and  the  ileum,  thickened,  flexed,  and  covered  with 
lymph:  its  root  was  found  invaginated  into  the  cecum.  "The  condition  was  as 
if  the  base  of  the  appendix  had  been  pushed  into  the  cecum,  carrying  part  of  the 


474  APPENDICITIS    IN    THE    CHILD. 

cecal  wall  with  it,  and  forming  a  depression  about  the  size  of  the  first  joint  of  an 
adull  index-finger,  from  which  the  appendix  sprung  like  the  stalk  of  a  mushroom." 
All  attempts  to  reduce  the  invagination  from  without  having  failed,  a  slit  was 
made  in  the  cecum  in  the  course  of  a  longitudinal  muscular  hand,  and  the  finger 
passed  into  the  bowel;  by  this  means  the  invagination  was  partly  reduced,  hut 
the  depression  was  still  no1  wholly  obliterated.  As  the  lumen  of  the  bowel  was 
nut  materiallj  encroached  upon,  the  opening  in  the  cecum  was  closed  and  the  ap- 
pendix  then  removed.     Its  cavity  was  completely  obliterated  at   the  root.     It  is 

not    stated    whether   a    drain    was    inserted. 

Iii  cases  where  the  inverted  appendix  is  the  only  portion  of  the  intussusception 
which  cannot  he  reduced,  it  is  best,  after  opening  the  cecum,  to  amputate  the 
appendix,  a  plan  pursued  successfully  by  Pitts  in  the  following  case  (Lancet, 
L897,  vol.  1,  p.  1602): 

13.  A  little  girl,  two  and  a  half  years  old.  was  admitted  to  St.  Thomas's  Hos- 
pital, her  mother  stating  that  three  and  a  half  months  before  she  hail  been  turn- 
ing head  over  heels,  immediately  after  eating  her  dinner,  when  she  suddenly  com- 
plained of  pain  in  her  abdomen.  She  continued  to  have  similar  attacks  of  pain 
of  short  duration  for  several  days,  the  abdomen  becoming  hard  and  rigid  while 
they  lasted.  The  bowels  were  relaxed  and  the  stools  contained  mucus  and  blood. 
Two  weeks  before  she  entered  the  hospital  a  protrusion  of  intestine,  four  inches 
long,  was  seen  at  the  amis  by  the  physician  who  attended  her.  and  a  tumor  could 
be  felt  in  the  abdomen  by  palpation.  The  rectal  protrusion  was  replaced,  after 
which  the  child  was  inverted  and  the  abdomen  kneaded,  during  which  process 
the  tumor  disappeared  with  a  gurgling  sound.  A  few  days  after  this,  however, 
she  became  worse,  and  on  examination  a  sausage-shaped,  freely  movable  tumor, 
which  changed  its  position  from  time  to  time,  was  found  in  the  position  of  the 
transverse  colon.  <  >n  operation,  a  median  incision  was  made  just  below  the  um- 
bilicus and  an  intussusception  at  once  discovered,  which  was  easily  reduced,  but 
after  complete  reduction  it  was  noticed  that  the  vermiform  appendix  was  not  vis- 
ible, its  normal  position  being  occupied  by  a  dimple.  An  elongated  swelling  could 
he  felt  through  the  cecal  wall,  resembling  the  thickened  appendix,  and  when  an 
incision  was  made  into  the  cecum  a  "chronically  inflamed  and  completely  inverted 
appendix  was  found."  As  all  attempts  at  further  reduction  failed,  the  appendix 
was  cut  away  in  loin  within  the  bowel,  and  its  base  sutured.  In  addition,  the 
peritoneal  coat  was  drawn  over  the  little  orifice,  the  incised  bowel  was  sutured, 
and  the  abdomen  closed — presumably  without  a  drain.  The  child  made  an  excel- 
lent recovery.  The  writer  remarks  that  the  inverted  appendix  was  probably 
the  primary  step  in  the  invagination. 

When  the  appendix  is  completely  inverted,  it  seems  hardly  necessary  to 
make  the  colic  incision,  as  was  done  here.  If  the  mesappendix  can  be  tied  off,  it 
ought  then  be  sufficient  to  ligate  and  divide  its  vessels  and  sew  up  the  little  pit 
at  the  inverted  base,  as  is  done  by  Edebohls  in  his  ordinary  operation  for  re- 
moval of  the  appendix  by  inversion,  after   which   the   appendix  sloughs   off 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  4<5 

within  the  bowel  and  passes  out  by  the  rectum.  Such  a  plan  has  the  ad- 
vantage of  avoiding  the  very  serious  risk  of  exposing  the  wound  to  the  often 
foul  cecal  accumulations,  as  occurred  in  a  case  reported  by  A.  II.  Knight  (New 
Zealand  Med.  Jour.,  1890-91,  vol.  4,  p.  106): 

14.  A  child,  thirteen  months  old,  sex  no1  stated,  was  taken  ill  with  vomiting 
and  great  pain  in  the  abdomen,  together  with  diarrhea  in  which  the  stools  contained 
some  blood.  Examination  of  the  abdomen  showed  only  an  indistinct  dulness, 
but  on  the  following  day  a  tumor  was  found  in  the  position  of  the  left  colon,  ex- 
tending from  the  margin  of  the  ribs  to  the  hips.  Intussusception  was  then  sus- 
pected, and  an  attempt  was  made  to  reduce  the  tumor  by  high  enemata.  with  partial 
success.  The  general  condition  improved,  but  as  the  tumor  persisted,  an  opera- 
tion was  performed  on  the  third  day.  A  hard  tumor  situated  above  the  umbili- 
cus was  brought  into  view,  but  all  attempts  at  reduction  failed.  The  appendix 
could  be  seen  projecting  from  the  invagination.  The  bowel  was  then  laid  open, 
and  the  valve  exposed  to  view,  when  it  was  found  in  a  putrid  condition.  The 
mortified  portion  was  resected,  but  the  child's  condition  was  so  bad  that  this  could 
not  be  satisfactorily  accomplished,  and  death  took  place  within  an  hour  after  the 
completion   of  the  operation. 

In  cases  of  old  intussusceptions,  in  which  the  appendix,  together  with  a 
portion  of  the  cecum,  is  either  invaginated  <>r  inverted,  the  chronic  inflammatory 
alterations,  which  are  characterized  by  great  thickening,  rigidity,  and  edema 
of  all  the  tissues  involved,  as  well  as  by  numerous  adhesions,  are  often  so 
marked  that  any  persistent  or  forcible  attempts  at  reduction  become  fraught 
with  the  utmost  risk  of  serious  injury  to  the  bowel,  or  even  its  complete  rupture. 
The  rule  may,  therefore,  be  laid  down  that  gentle  efforts  only  are 
warranted  in  attempting  to  effect  a  r  e  d  u  c  t  i  o  n .  In 
chronic  irreducible  intussusceptions  a  more  radical  plan  of  treatment  must  be 
adopted.  Excision  of  the  appendix  with  the  adjacent  portion  of  the  cecum 
should  be  the  rule  here,  as  illustrated  in  the  case  of  McGkaw.  already  cited 
i  No.  3),  in  which  he  cut  through  the  cecum  at  the  neck  of  the  intussusception, 
just  where  the  infolding  occurred,  removing  the  invaginated  portion,  and  leaving 
behind  at  least  an  inch  or  more  of  the  cecal  wall  extending  from  the  cut  edge  to 
the  ileocecal  orifice.  This  opening  he  united  by  a  double  row  of  catgut  sutures, 
ami  covered  the  wound  with  the  omentum. 

Amputation  of  the  entiro  cecum  with  the  appendix  has  been  successfully 
practised  by  D.  Ackermann  (Beitr.  /.  klin.  Chir.,  1902,  vol.  37.  p.  580  : 

15.  A  delicate  little  girl,  four  years  old,  had  a  fall  from  a  chair  upon  her  side, 
after  which  she  was  subject  to  attacks  of  abdominal  pain  resembling  colic,  which 
lasted  from  a  few  hours  to  a  day,  and  were  accompanied  by  vomiting  of  slimy  green- 
ish material.  These  attacks  at  first  occurred  at  intervals  of  a  day  or  two.  and 
then  came  daily.  The  bowels  were  generally  regular.  Imt  there  was  occasionally 
diarrhea  or  constipation,  and  blood  was  often  found  in  the  stools.  At  the  end  of 
.six  months,  when  the  child  was  admitted  to  the  hospital,  the  attacks  of  pain  and 


176  APPENDICITIS    IN'    Till)    CHILD. 

vomiting  were  constant,  and  the  genera]  condition  was  had.  In  the  left  Hank 
was  a  round  tumor,  clastic  to  pressure,  and  the  size  of  a  goose's  egg,  while  above 
it  lay  numerous  hard  lumps,  varying  in  size  from  a  hazelnut  to  a  walnut ;  the  red  um 
was  empty,  bul  the  tumor  could  be  felt  between  the  finger  in  the  rectum  and  one 
outside.  A  diagnosis  was  made  of  chronic  intussusception.  On  operation,  the 
tumor  which  had  been  fell  from  the  exterior,  proved  to  be  the  cecum  and  colon 
invaginated  into  the  sigmoid  flexure,  while  the  vermiform  appendix  could  be  dis- 
tinctly felt  as  a  round  thick  cord  through  the  intussuscipiens.  Reduction  was 
effected  as  far  as  the  valve,  bul  as  it  was  impossible  to  reduce  the  remaining  in- 
vagination nil  account  of  adhesions,  this  portion  was  resected,  and  the  patient 
made  a  good  recovery.  Examination  of  the  resected  portion  showed  the  appen- 
dix invaginated  into  the  cecum,  and  so  closely  attached  that  a  reduction  was  im- 
possible, the  whole  mass  forming  a  hard  rigid  tumor.  going  over  into  gangrene. 

The  plan  of  resecting  the  entire  cecum  with  a  por- 
tion of  the  ileum  as  well,  has  been  successfully  employed  by 
I).  B.  Lees  (Lancet,  L898,  vol.  1,  p.  I  100): 

16.  A  hoy,  four  ami  a  half  years  old,  was  admitted  to  St.  .Man's  Hospital  on 
account  of  an  intussusception,  which  was  relieved  by  irrigation  so  completely  that 
lie  was  discharged  in  two  days.  He  had  repeated  returns  of  the  same  affection, 
which  was  as  often  relieved  by  the  same  measures,  until  aboul  four  months  later, 
when  the  tumor  could  no  longer  he  entirely  reduced,  and  his  condition  became 
serious.  (  >n  operation,  it  was  found  that  the  parts  concerned  were  the  lower  end 
of  the  ileum  and  the  cecum,  and  as  reduction  could  not  he  accomplished,  these  were 
excised,  the  ileum  being  divided  two  or  three  inches  above  the  ileocecal  valve  and 
the  colon  some  inches  beyond  the  cecum.  The  ends  of  the  intestine  were  approxi- 
mated by  I.emhert's  sutures:  nothing  is  said  of  drainage.  The  patient  made  a 
irodd  recovery.  Examination  of  the  excised  specimen  showed  that  the  posterior 
wall  of  the  cecum,  carrying  with  it  the  appendix,  had  been  invaginated  into  the 
ascending  colon:  and  the  ileocecal  valve  had  been  dragged  upon,  carrying  with 
it    about    one   inch  of  the  ileum. 

In  cases  where  the  diseased  process  has  progressed  so  far  as  to  involve  the 
colon  as  well  as  the  ileum,  it  hecoines  necessary  to  employ  the  last  method  on 
our  list :  a  tn  p  u  t  a  t  i  o  u  o  f  t  li  e  c  e  c  u  m  ,  wit  li  b  o  t  h  ile  u  m  and 
c  o  1  o  n  a  s  f  a  r  as  t  h  e  y  a  r  e  i  n  v  o  1  v  e  d  .  The  following  case,  reported 
by  (i.  .1.  Westermann,  is  the  only  one  I  have  met  with  in  which  such  extensive 
measures  were  necessary  (Weekblad  van  det  Neederlandsch  Tijdschrifi  run  Genes- 
kunde,  No.  24 :  see  also  abstract  in  Beitr.  j.  klin.  ( 'hir.,  1903,  vol.  .'37.  p.  58.r>) : 

17.  A  little  girl,  six  years  old.  had  a  chronic  intussusception,  and  on  opera- 
tion the  greater  part  of  the  ascending  colon  (15  cm.),  the  cecum,  and  a  Ions  piece 
of  ileum  (I'd  cm.)  were  removed.  The  vermiform  appendix,  which  was  fi  cm.  long, 
and  the  thickness  of  an  index-finger,  was  found  inverted  I  umgestulpt)  into  the  cecum. 

In  all  cases  the  amputation  should  lie  done  in  the  health}'  tissues  of  the  bowel, 
above  the  inflamed  thickened  portion.     The  resected  and  sutured  bowel  ought 


SYMPTOMATOLOGY   AND    DIAGNOSIS.  4/ 1 

then  to  be  brought  down  to  the  wound,  and  an  iodoform  gauze  drain  inserted. 
This  is  better,  I  think,  than  covering  the  bowel  with  omentum.     If  the  oper- 
ation demands  haste  one  of  .Murphy's  buttons  is  the  best  expedient. 
The  following  cases  complete  my  collection: 

18.  Chaffey  {Lancet,  1888,  vol.  2.  p.  17).  A  boy,  three  years  old,  was  ad- 
mitted to  the  Hospital  for  Sick  Children,  Brighton,  with  a  history  of  vomiting, 
and  the  passage  of  mucus  and  blood  from  the  bowels  for  ten  days.  <  >n  examining 
the  abdomen,  an  elongated  sausage-shaped  tumor  could  be  outlined  in  the  region  of 
the  transverse  colon,  which  was  not  tender  to  the  touch  but  descended  at  each  res- 
piration. The  next  day  the  child  was  semi-collapsed,  and  examination  under  chloro- 
form showed  that  the  tumor  was  less  defined,  but  a  distinct  swelling  could  be  made 
out  in  the  right  hypochondrium.  For  twelve  days  the  patient  grew  weaker,  the 
tumor  appearing  and  disappearing,  blood  and  mucus  being  occasionally  present  in 
the  stools,  when  he  died  of  exhaustion.  The  autopsy  showed  the  omentum  drawn 
over  to  the  right  side,  and  fixed  to  the  parts  in  the  vicinity  of  the  cecum  by  old 
adhesions;  the  position  of  the  cecum  was  occupied  by  a  round  tumor,  about  three 
inches  long,  composed  of  the  cecum  invaginated  on  itself  along  the  ileocecal  valve, 
with  bands  of  old  adhesions  holding  the  parts  together.  The  distal  end  of  the 
appendix  could  not  be  found,  though  it  was  diligently  sought  for;  the  proximal 
end  had  become  inverted  so  as  to  form  a  little  polypoid  projection  about  one  inch 
long  in  the  cavity  of  the  cecum,  close  to  the  ileocecal  valve.  The  apex  of  the 
polypoid  protuberance  presented  a  well-marked  ostium  leading  into  a  tubular 
cavity  about  half  an  inch  long. 

19.  Enderi.ex  (Munch,  med.  Wochcmchr.,  July  17,  1900,  p.  1021,  abstract 
Bcitr.  j.  Min.  Ghir.,  1903,  vol.  37,  p.  587).  A  boy,  two  and  a  half  years  old. 
was  seized  with  severe  colicky  pain  over  the  umbilicus,  accompanied  by  stools 
in  which  blood  and  mucus  were  mixed  with  normal  fecal  movements.  When 
admitted  to  a  hospital  at  the  end  of  five  months,  he  had  a  sharply  defined  tumor 
lying  transversely  in  the  epigastric  region,  which  gradually  developed  in  the  direc- 
tion of  the  transverse  colon,  until  it  finally  lay  across  the  upper  half  of  Poupart's 
ligament  on  the  left  side,  and  at  the  end  of  about  five  weeks  it  could  be  felt  in  the 
rectum.  At  the  tip  of  the  prolapsus  there  was  a  knob-shaped  projection,  with  a 
short  narrow  lumen,  from  the  base  of  which  the  lumen  of.  the  intestine  could  be 
reached.  The  child  died  about  seven  months  after  the  first  symptoms  made  their 
appearance,  with  all  the  symptoms  of  acute  perforative  peritonitis.  At  the  au- 
topsy, the  beginning  of  the  invagination  was  found  near  the  middle  of  the  transverse 
colon,  from  which  it  extended  down  to  the  anal  region,  a  distance  of  about  35  cm. 
Its  outer  coat  had  several  deep  fissures,  through  which  two  short  secondary  invagina- 
tions had  formed.  The  tumor  was  sharply  flexed  at  its  entrance  into  the  true 
pelvis,  and  at  the  flexion  there  were  two  perforations.  The  starting-point  of  the 
invagination  was  at  the  ileocecal  opening,  and  not,  as  appeared  in  life,  at  the  knob 
formed  by  the  partly  inverted  appendix  (der  teilweise  umgestulpte) ;  the  ileocecal 
invagination  had  traversed  the  whole  colon  in  the  space  of  seven  months. 

20.  W.  H.  Bishop  (Chironian,  1903,  vol.  20.  p.  81).  A  boy.  five  years  old.  was 
admitted  to  the  Flower  Hospital  with  great  pain  in  the  abdomen,  vomiting,  and  a 


178  APPENDICITIS    IX    THE    CHILI). 

rapid  pulse.  On  inspection,  a  mass  was  observed  protruding  from  the  anus,  which 
cm  one  side  had  an  elongated  sausage-shaped  excrescence  resembling  an  in- 
verted  appendix.  On  palpation  a  tumor  was  found  on  the  lefl  side  of  the 
abdomen,  over  the  upper  pari  of  the  descending  colon.  The  mass  protruding  from 
the  anus  was  replaced,  bu1  immediately  returned.  An  anesthetic  was  then  given 
and  the  excrescence  amputated  close  to  the  bowel.  The  intussusception  was  then 
again  replaced  and  the  lower  bowel  inflated  with  oxygen  through  a  rectal  tube, 
with  the  child  in  an  inverted  position.  The  mass  then  disappeared  from  the 
rectum.  The  vomiting  and  abdominal  pain  soon  returned  and  the  mass  on  the 
lefl  side  was  again  prominent.  Laparotomy  was  then  dune,  but  it  was  nol  possi- 
ble in  deliver  any  portion  of  the  intussusception,  nor  to  drag  out  the  invaginated 
portion  by  traction  on  the  upper  section.  Inflation  of  the  rectum  was  again  prac- 
tised, and  by  grasping  the  rectum  and  sigmoid  flexure  and  keeping  up  a  kneading 
squeezing  motion  from  below  upward,  the  tumor  was  moved  upward  as  far  as  the 
ileocecal  region,  where  it  disappeared.  It  was  now  seen  thai  in  place  of  the  appen- 
dix, there  appeared  its  stump  inverted,  with  the  ligature,  of  course,  within 
the  lumen  of  the  bowel,  and  constricting  all  the  coats  of  the  intestine.  Unin- 
terrupted recovery. 

Hip  Disease.  —II.  V.  Gibney,  in  1881,  first  called  attention  to  the  dange  r 
of  mistaking  chronic  appendicitis  for  hip  disease. 
and  the  article  he  then  published  under  the  title  "  Perityphlitis  in  children,  illus- 
trating /minis  iii  the  differential  diagnosis  <>j  hip  di  ea  e"  (Amer.  Jour.  Med. 
Sci.,  1881,  N.  S.,  vol.  81,  p.  119),  still  remains  the  besl  contribution  to  this 
branch  of  the  subject,  although  it  has  been  made  a  matter  of  comment  by 
more  than  one  writer.  It  will  be  a  sufficienl  warning  to  the  unwary  to 
state  that  an  error  in  diagnosis  between  these  two  conditions  has  been  com- 
mitted by  surgeons  of  excellent  reputation,  and  therefore  coxitis  must  always 
be  considered  as  a  possibility  in  uncertain  cases. 

Ill  GlBNEY'S  Original  article  he  cites  li  cases  occurring  within  his  personal 
experience. 

One    of    the   six    (the    fourth),  a   hoy   six   years  old,  was   carried   into   tl C( 

of  the  Massachusetts  General  Hospital,  because  he  was  unable  to  walk,  and  gave 
the  following  history:  He  had  been  in  perfect  health  and  sound  of  limb  until  three 
weeks  before,  when  he  had  a  fall.  During  the  following  night  he  began  to  have 
pain  in  the  righl  hip;  the  next  day  he  could  scarcely  walk:  and  four  or  five  days 
later,  when  seen  by  a  surgeon  of  distinction,  he  was  pronounced  suffering  from 
hip  disease,  a  weight  and  pulley  being  applied  as  appropriate  treatment!  During 
the  next  three  weeks  the  patient  suffered  much  pain  in  the  righl  knee  and  groin, 
severe  enough  to  require  anodynes  at  night.  His  rectal  temperature  on  admission 
to  the  hospital  was  101  1.:  he  was  much  emaciated ;  his  tongue  was  heavily  coated; 
and  he  was  unable  to  stand  without  bearing  his  whole  weighl  upon  the  left  limb, 
while  keeping  the  lefl  semiflexed  at  the  hip.  with  the  knee  rotated  inward:  walking 
was  entirely  out  of  the  question.  Sitting  on  the  side  of  the  bed,  he  voluntarily 
crossed  the  right  leg  over  the  left  knee:  lying  prone,  nothing  abnormal  was  seen, 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  479 

except  a  deviation  of  the  lumbar  spine  to  the  left;  lying  on  the  back,  he  volun- 
tarily flexed  the  thigh  on  the  pelvis  completely.  He  could  both  abduct  and  ad- 
duct  the  limb,  but  In-  could  not  extend  it  beyond  '.»(>  degrees  without  pain,  and.  if 
passive  extension  was  tried,  he  resisted  and  cried.  Rotation  could  be  easily  made 
if  carefully  executed:  pressure  over  the  trochanter  in  the  line  of  the  neck  as  well 
as  concussion  gave  no  pain.  There  was  no  infiltration  about  the  trochanter,  nor 
below  Poupart's  ligament.  The  abdominal  walls  were  a  little  retracted,  and  there 
was  no  tenderness  nor  infiltration  in  either  ileocostal  space  n<>r  in  the  lift  fossa,  but 
in  the  right,  tumefaction  could  Vie  distinctly  felt  within  a  triangular  area,  bounded 
above  by  a  line  extending  from  top  of  the  crest  of  the  ilium  to  the  median  line,  just 
below  the  navel.  There  was  dulness  and  excessive  tenderness,  but  no  well-defined 
tumor.  A  diagnosis  of  perityphlitis  was  made,  and  the  case  treated  by  rest  in 
bed,  laxatives,  vesication,  and  poultices  or  hot  fomentations.  Under  these  measures 
the  symptoms  gradually  subsided,  and  in  less  than  four  weeks  after  the  child  entered 
the  hospital,  he  was  completely  cured.  The  functions  of  the  hip  were  perfect,  and 
when  seen  again,  three  months  later,  he  was  as  well  as  ever. 

Gibney's  remaining  cases,  while  not  so  striking  as  this  one,  demonstrate 
plainly  that  such  an  error  in  diagnosis  is  easily  made  during  childhood.  Another 
ease  of  the  same  kind  i~  given  by  H.  Myntek  (Appendicitis,  1S97): 

A  girl,  thirteen  years  old,  was  taken  ill  with  severe  pain  in  the  ileocecal  region. 
A  physician  made  a  diagnosis  of  appendicitis,  and  the  patient  recovered  rapidly 
under  medical  treatment.  For  six  months  she  continued  well,  but  then  com- 
plained of  severe  pain  in  her  right  hip  and  became  quite  lame.  She  saw  a 
physician,  who  told  her  she  had  hip-joint  disease,  on  account  of  which  she  entered 
a  hospital  for  treatment.  Upon  examination,  a  hard,  swollen  appendix  was  felt, 
extending  from  McBumey's  point  in  an  upward  direction.  It  was  intensely  tender 
on  pressure,  producing  pain  in  the  right  hip,  although  both  hip-joints  were  nor- 
mal. On  operation,  the  appendix  was  found  to  be  six  inches  lung,  lying  flat  on 
the  outside  of  the  cecum,  and  completely  bound  down  by  old  adhesions.  It  was 
stiffened  and  thickened;  the  mucous  membrane  was  enormously  thickened  and 
softened,  with  here  and  there  intense  local  congestion,  amounting  at  one  spot  to 
necrosis.     The  appendix  was  removed,  and  the  patient  made  a  iz 1  recovery. 

Such  an  error  in  diagnosis  as  these  cases  illustrate,  will  be  avoided  by  the 
physician  who  sits  down  carefully  at  the  bedside  and  spends  a  little  time  in 
palpating  and  compressing  the  hips,  jn  palpating  the  lower  abdomen,  and  in 
slightly  rotating  and  extending  the  leg.  the  attention  of  the  child  being  at  the 
same  time  diverted.  In  any  case  of  lingering  doubt,  an  examination  should  be 
made  under  an  anesthetic,  and  the  patient  watched  from  day  to  day. 

Hernia. — Of  56  cases  of  hernia  of  the  appendix  analyzed  by  Rivet,  13,01*23 
per  cent.,  occurred  under  the  age  of  thirteen.  It  is  naturally  more  frequent  in 
males  than  in  females,  occurring  in  the  proportion  of  nearly  70  per  cent,  in  the 
former  to  30  in  the  latter,  including  all  ages,  while  the  inguinal  form  is  much  the 
commonest  (J.  H.  Jopsox.  Proc.  Path.  Soc.  Phihi.,  1900).      These  hernias  may 


480  APPENDICITIS    I.N    THE    CHILD. 

be  divided  into  two  classes:  congenita]  and  acquired,  congenital  hernia  being 
understood  as  a  congenital  predisposition  which  manifests  itself,  it  not  at  birth, 
at  least  soon  afterward.  It  would,  perhaps,  be  more  literally  correct  to  use  the 
term  "infantile"  to  designate  a  hernia  occurring  in  the  earliest  years  of  life, 
and  "acquired"  for  the  forms  developing  later. 

G.  A.  Piersol,  in  a  clear,  thoughtful  article  on  "Early  infantile  hernia 
of  the  vermiform  appendix"  (Univ.  Penn.  Med.  Bull.,  Oct.,  1901),  Bays: 

"The  favorable  conditions  offered  by  the  vaginal  process  before  birth  for 
the  engagement  of  the  neighboring  parts  of  the  intestine  are  universally  recog- 
nized. That  such  involvement  does  not  more  frequently  occur  is  probably  due, 
as  stated  by  Schmidt,  to  the  preponderance  of  head  presentations,  the  absence 
of  respiratory  movements,  the  inactivity  of  the  abdominal  muscles,  and  the 
meagre  peristalsis  of  the  fetal  intestines.  Additional  evidence  of  the  influence 
of  gravity  is  shown  by  the  fact  that  although  11  percent,  of  all  inguinal 
hernias  occur  during  the  first  year,  they  usually  do  not  appear  until  after  the 
third  month,  or  not  until  the  infant  is  carried  in  an  upright  position." 

The  causes  of  the  descent  of  the  vermiform  appendix  into  the  hernial  sac 
(inguinal  canal)  are:  (1)  an  anatomical  attachment  connecting  the  appendix 
closely  with  the  cord  called  the  plica  vascularis,  analogous  to  dado's  ligament 
in  the  female,  extending  from  the  cecum  and  appendix  to  the  infundibular  pelvic 
ligament  and  the  ovary;  or  (2)  to  adhesions  of  the  appendix  to  the  migratory 
peritoneum  adjacent  to  the  cord;  or  (3)  to  an  open  inguinal  ring  with  a  preter- 
naturally  long  appendix;  or,  (4),  what  amounts  to  the  same  thing,  a  cecum 
with  a  long  mesentery. 

In  a  case  described  by  Piersol,  of  a  negro  infant  about  three  months  old, 
the  cecum,  which  was  of  the  typical  infantile  form,  occupied  a  position  con- 
siderably lower  than  usual  in  the  right  iliac  fossa.  The  entire  length  of  the 
appendix  lay  in  a  hernial  sac,  extending  a  little  more  than  half-way  to  the  hot- 
torn  of  the  scrotum.  The  appendix  was  Sf  mm.  in  length,  or  nearly  two  and 
a  half  times  longer  than  the  average  length  at  birth,  which,  as  determined  by 
RiBBERT,  is  34.1  mm.  There  was  a  circumscribed  attachment  of  this  appendix 
to  the  wall  of  the  sac,  as  well  as  a  marked  thickening  of  the  latter,  from  which 
Piersol  concluded  that  the  adhesion  of  the  appendix  was  the  result  of  an  early 
inflammatory  process,  and  not  of  persistent  fetal  attachment. 

The  diagnosis  of  a  hernia  of  the  appendix  is  possible  when  the  worm- 
like organ  can  be  palpated  within  tiie  sac.  especially  when,  after  palpation, 
upon  inversion  of  the  child,  it  slips  out  of  the  sac.  It  is  more  easily  felt  when 
inflamed,  thickened,  and  rigid.  A  diagnosis  will  be  made  more  frequently 
if  the  displacement   is  always  suspected  and   felt    for. 

The  sequela?  of  such  a  misplacement  may  be  those  of  an  appendix  normally 
placed,  with  the  added  liability  to  inflammation  from  trauma,  kinking,  ad- 
hesions, the  accumulation  of  foreign  material,  or  strangulation  at  the  neck  of 
the  sac.     An  appendix  in  a  hernial  sac  may  become  irreducible  in  consequence 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  481 

of  inflammation  and  adhesions  contracted  with  the  surrounding  part;  or  sup- 
puration may  be  sot  up  in  the  neighborhood,  forming  an  abscess,  opening  ex- 
ternally and  creating  a  fecal  fistula;   or,  finally,  general  peritonitis  may  result. 

The  operation  for  this  condition  may  be  relatively  simple,  and  it  can  be 
performed  on  the  surface  of  the  body,  much  like  an  appendicitis  operation, 
so  long  as  it  is  done  early,  and  the  disease  remains  limited  to  the  extra- 
peritoneal pouch.  Neglected  cases,  however,  may  be  associated  with  a  general 
peritoneal  infection  with  all  its  attendant  risks. 

Ovarian  Disease. — Several  instances  have  been  reported  of  a  mistake  in 
diagnosis  between  appendicitis  and  ovarian  disease  in  the  child.  Porter,  in 
1892,  reported  the  case  of  a  little  girl  eleven  years  old,  in  which  the  mistake 
arose  from  the  twisting  of  the  pedicle  belonging  to  a  small  ovarian  cyst.  The 
little  patient  had  had  three  previous  attacks  of  pain  in  the  region  of  the  right 
iliac  fossa,  all  of  which  had  come  on  rather  suddenly  and  disappeared  as  quickly; 
one  after  a  warm  rectal  enema,  the  others  spontaneously.  She  had  never  men- 
struated, nor  did  she  seem  to  be  near  puberty.  When  seen,  forty-eight  hours 
after  the  beginning  of  the  attack,  there  was  a  slight  elevation  of  temperature 
with  pain  and  exquisite  tenderness  in  the  right  iliac  fossa,  and  a  sensitive  tumor 
just  above  Poupart's  ligament.  The  tenderness  and  tumor  seemed  to  be  rather 
too  far  down  for  the  appendix,  and  the  diagnosis  of  appendicitis  was  made 
with  some  hesitation,  disease  of  the  uterine  adnexa  being  considered  and  ex- 
cluded. At  the  operation  a  vertical  incision  through  the  right  rectus  revealed 
a  right  ovarian  cyst  the  size  of  a  small  egg,  its  pedicle  being  slightly  twisted 
by  three  complete  turns,  and  showing  beginning  gangrene.  A  similar  case  of 
twisting  of  the  pedicle  is  mentioned  by  Fitz,  and  vox  Faber  has  reported  a 
case  of  "Steatoma  of  the  ovary"  with  perforation  of  the  appendix,  in  a  child 
three  and  a  half  years  old.  Here  the  symptoms  were  colicky  pain  in  the  ab- 
domen with  marked  enlargement,  and  a  worm-like  swelling  in  the  right  iliac 
fossa.  The  abdominal  enlargement  increased  until  the  child  could  not  stand, 
and  was  accompanied  by  edema  of  the  right  foot.  Death  took  place  at  the 
end  of  six  months  from  the  beginning  of  the  illness,  and  at  the  autopsy  the 
right  ovary  was  found  converted  into  a  ''steatoma,  weighing  sixteen  and  a 
half  pounds,  more  than  half  of  the  body-weight.  In  the  middle  of  the  tumor 
was  a  cavity  containing  serum,  and  a  bluish  substance,  in  size  and  appearance 
resembling  a  pregnant  uterus.  In  the  vermiform  appendix  was  a  pinworm, 
which  had  bored  through  the  tip  of  the  appendix  to  the  tumor."  {Med.  Cor.- 
Bl.  d.  wurttemb.  arztl.  Verhandlstulig.,  1885,  Bd.  25,  p.  221.) 

Actinomycosis. — Karewski  (Dtsch.  med.  Wochen.,  1897,  Bd.  33,  p.  321) 
records  the  following  case: 

A  child  had  an  appendicitis  with  considerable  exudate,  hut  slight  general  dis- 
turbance.    On  recovery  he  was  sent  to  the  country,  when  he  began  to  show  much 
peculiarity  of  gait,  in  the  form  of  persistent  flexion  at  the  hip-joint,  which  was 
attributed  to  weakness.     Soon  after  his  return  to  the  city  he  became  ill  again,  with 
31 


1SJ  APPENDICITIS    IX    THE    CHILD. 

more  general  symptoms  of  an  indefinite  description,  and  nothing  characteristic  ol 
appendicitis.  At  last  a  swelling  developed  in  the  right  inguinal  region,  eventually 
occupying  the  right  lower  abdomen,  where  there  was  a  board-like  infiltration, 
arising  from  an  abscess  which  had  broken  on  the  outer  side  of  the  thigh,  after  passing 
the  fossa  vasorum,  ami  tinder  Poupart's  ligament.  There  was  no  fever  and  no  pain ; 
some  resistance'  could  lie  fell  through  the  rectum.  When  an  incision  was  made, 
the  golden-yellow  granulations  characteristic  of  actinomycosis  were  found.  The 
ahscess  was  traced  as  tar  back  as  the  brim  of  the  pelvis,  and  behind  the  peritoneum; 
Poupart's  ligament  was  divided,  after  which  the  incision  was  carried  over  to  the 
bladder  and  the  region  of  the  appendix  exposed.  'The  author  says  that  it  was  clear 
there  was  an  affection  of  the  appendix,  because,  alter  a  few  days,  and  with  the 
diminution  of  the  swelling,  a  tit-like  process  of  the  intestine  was  visible  in  the  wound, 
from  which  fecal  matter  escaped.  After  some  deceptive  improvement,  an  exten- 
sion of  the  process  between  the  liver  and  the  bladder  was  discovered.  The  cast 
had   not   terminated   when   reported. 

TREATMENT. 

The  treatment  of  an  attack  of  appendicitis  in  a  child  should  begin  when 
the  disease  is  in  its  earliest  stages,  or  even  when  it  is  merely  suspected.  If  the 
child  has  an  attack  of  acute  gastro-intestinal  disturbance  with  vomiting  and 
some  pain  in  the  right  iliac  fossa;  or  if  there  is  a  mild  incipient  attack  of  catar- 
rhal appendicitis,  it  must  he  kept  quiet  in  lied,  on  restricted  liquid  diet,  with 
enough  opium  to  set  the  bowels  at  rest,  and  with  tin  ice-bag  applied  over  the 
appendix.  It  is  of  the  utmost  importance  in  these  prodromal  stages  to  avoid 
such  active  treatment  as  purgation  and  eneniata,  which  are  calculated  to  do 
so  much  harm  in  an  appendicitis. 

A  patient  detained  in  bed,  while  the  diagnosis  is  uncertain,  should  be  closely 
watched  by  physician  and  nurse,  and  careful  note  of  the  symptoms  kept  from 
hour  to  hour.  If  the  physician  judges  that  an  operation  may  be  needed,  he 
should  have  all  his  plans  made  in  advance  to  act  with  the  utmost  promptitude 
when  the  decision  is  reached. 

I']  v  i>  r  y  c  a  s  e  o  I'  f  r  a  n  k  appendicitis  in  a  child  shoul  d 
be  operated  upon,  if  seen  in  the  early  stages  of 
the  disease.  If  seen  at  a  later  date,  that  is  to  say,  from  the  third  or 
fourth  day  on,  it  is  best  not  to  operate,  if  there  are  decided  signs  of  improve- 
ment, as  shown  by  lessened  temperature,  slower  pulse,  and  such  amelioration 
in  the  general  condition  as  is  evident  to  a  practised  eye,  but.  above  all,  by  a 
regression  in  the  local  symptoms,  particularly  in  the  absorption  of  theexudate. 

So  many  cases  of  appendicitis  in  children  end  in  a  general  peritonitis,  and 
so  many  (Selter  estimates  about  one-half)  end  in  the  formation  of  tin  ab- 
scess, that  it  should  lie  a  rule  to  give  prompt  surgical  relief  as  soon  as  a  clear 
diagnosis  is  made.  So  eminent  a  pediatrist  as  Roach  (Pediatrics,  1896,  p.  sss> 
has  declared  that  "inflammation  of  the  appendix  ceci  is  essentially  a  surgical 
disease,  and  is  one  which  under  till  circumstances  should  lie  placed  immediately 


SYMPTOMATOLOGY    AND    DIAGNOSIS.  483 

in  the  hands  of  those  who  are  skilled  in  abdominal  surgery.  From  my  obser- 
vation of  this  disease  I  am  so  strongly  impressed  with  this  fact  that  I  consider 
an  extended  description  of  it  in  medical  lectures,  and  by  physicians,  out  of 
place." 

Selter,  however,  recommends  that  in  every  case,  even  with  severe  symp- 
toms, a  course  of  expectant  treatment  should  be  tried  for  one  or  two  days,  and 
then,  if  there  is  no  improvement;  if  the  swelling,  which  is  being  watched  by 
rectal  examinations,  is  found  increasing  in  size;  and  if  the  peritoneal  pockets 
arc  filling  out,  he  declares  there  is  no  time  to  lose.  I  feel  sure,  however,  that 
this  is  too  great  conservatism,  and  will  often  prove  fatal  in  a  long  series  of 
cases.  If  the  diagnosis  is  clear,  and  if  a  good  surgeon  can  be  had,  it  is  better 
to  operate  a  few  times  too  often  than  to  regret  having  occasionally  post- 
poned doing  so.  The  rule  may,  therefore,  be  laid  down,  that  operation 
should  always  be  performed:  when  the  symptoms  are  progressive;  when  there 
is  increase  in  fever,  in  pulse-rate,  and  in  the  exudate;  when  vomiting  persists; 
and  when  tympany  is  present.  If  operation  has  been  postponed  on  account 
of  general  improvement,  and  the  exudate,  which  is  being  closely  watched  by 
careful  palpation  above  as  well  as  through  the  rectum,  does  not  diminish  after 
five  or  six  days,  it  is  better  to  operate  than  to  risk  septic  infection  from  a 
concealed  focus  of  suppuration. 

If  a  child  has  had  a  number  of  attacks,  the  interval  operation  is  to  be  pre- 
ferred, on  account  of  its  safety;  skilled  operators  estimating  the  risk  of  opera- 
tion at  this  date  as  0  per  cent. 

When  a  child  has  survived  an  attack  of  appendicitis,  and  a  mass  or  a  cord 
remains  in  the  iliac  fossa,  there  is  less  danger  in  operating  and  removing  the 
appendix  than  in  risking  a  sudden  general  peritonitis  from  the  rupture  of  a 
small  abscess  left  behind  in  this  way. 

When  an  abscess  has  formed,  the  incision  should  be  made  over  the  most 
prominent  part,  at  any  point  between  the  median  line  and  the  anterior  supe- 
rior spine.  The  incision  should  always  be  a  large  one,  and  an  extensive  trans- 
verse incision,  such  as  Karewski  has  made  use  of  in  some  instances,  may  some- 
times be  required.  Two  incisions,  one  on  the  right  and  one  on  the  left  side, 
are  necessary  more  often  in  children  than  in  adults;  several  instances  have 
occurred  in  children  where  death  was  due  to  an  abscess  on  the  left  side  which 
had  been  overlooked.  An  incision  on  the  left  side  alone  should  never  be  con- 
sidered sufficient.  As  a  rule,  it  is  best  to  do  as  little  as  possible  beyond 
thoroughly  opening  and  evacuating  the  abscess  and  removing  the  pus.  If 
the  abdominal  cavity  is  opened  by  accident,  the  utmost  care  must  be  taken  to 
prevent  the  entry  of  pus,  and  the  opening  should  at  once  lie  plugged  with 
gauze.  Broca  has  in  many  cases  successfully  adopted  the  plan  of  opening  the 
abscess  and  clearing  up  the  suppuration,  and  then  at  a  later  date  performing  a 
secondary  operation  to  remove  the  appendix.  It  is  best  to  avoid  extensive 
resection   above   the   omentum   in    large   abscess    cases.     Karewski    has  often 


|s  I  APPENDICITIS    l\    THE    CHILI). 

broughl  nut  the  uecrotic  or  deeply  infected  omentum,  and  left  it  lying  on  tlio 
surface,  where,  if  it  is  properly  protected  and  rendered  harmless,  it  may  slough 
off  and  granulate,  or  it  can  be  drawn  back  again  into  the  abdominal  cavity. 

In  every  operation  it  is  well  to  stimulate  the  patient  throughout  with  small 
doses  of  brandy  in  warm  enemata,  or  small  doses  of  strychnine,  from  ,-',,  to  ,  ',  „ 
of  a  grain  hypodermically,  given  two  or  three  times,  and,  above  all,  to  keep 
up  the  vitality  by  avoiding  exposure  of  the  surface  of  the  body,  by  operating 
in  a  warm  room,  and  by  keeping  the  little  patient  warm  on  a  blanket  with  hot- 
water  bags  beneath.    The  preparations  for  the  operation  should  be  so  carefully 

made  thai  the  moment  the  child  is  ready,  the  operator  will  he  able  to  begin 
and  advance  to  a  conclusion  without  delays.  The  delicate  tissues  of  the  ab- 
domen must  he  handled  with  extreme  care,  and  adhesions  clearly  distinguished 
from  bowel  before  cutting. 

If  the  child  is  very  restless  after  the  operation,  and  cannot  he  readily  re- 
strained by  the  nurse,  a  Bradford  frame  affords  an  excellent  means  of  restrain- 
ing it  in  a  relatively  immobile  posture  for  the  first  few  days,  while  the  infected 
area  is  being  walled  off  from  the  peritoneal  cavity  at  large. 

Even  desperate  cases  of  general  peritonitis  should  he  given  a  chance.  There 
is  absolutely  no  hope,  under  such  circumstances,  without  an  operation,  and 
tlnre  is  always  a  possibility  of  recovery  with  one.  Karewski  relates  a  case 
in  which  he  positively  refused  to  operate,  because  the  child,  which  was  brought 
to  him  with  a  profuse  peritonitis,  was  moribund  and  pulseless,  but  the  mother 
begged  so  piteously  for  some  action  that  he  opened  the  abdomen  in  the  median 
line,  cleansing  it  as  well  as  he  could,  and  tamponing  the  wound  without  sew- 
ing. The  child  recovered.  Other  cases  of  recovery  under  the  most  desperate 
and  apparently  hopeless  conditions  are  reported.  Extensive  incision  under  a 
cocaine  solution  is  a  method  which  might  be  favorably  employed  in  cases  such 
as  these. 


CHAPTER  XXI. 
TYPHLITIS. 

There  is,  perhaps,  no  subject  in  the  whole  realm  of  medicine  in  regard  to 
which  the  views  of  the  profession  have  undergone  such  a  complete  revolution 
as  that  of  inflammatory  affections  of  the  right  iliac  fossa.  The  medical  his- 
torian traces  the  evolution  of  knowledge  concerning  them  from  decade  to  de- 
cade, through  the  past  century,  with  ever-increasing  interest,  and  notes  with 
surprise  how  often  keen  and  well-trained  observers,  in  possession  of  facts  which 
should  have  afforded  a  right  understanding  of  the  nature  of  these  affections, 
have  yet  failed  to  draw  the  simple  conclusion  so  abundantly  warranted  by  the 
premises.  The  records  of  the  subject  closely  resemble  the  mortifying  history 
of  the  search  for  the  cause  of  malaria,  in  which  a  few  facts  patent  to  everybody 
contained  the  solution  of  the  problem.  Where,  to-day,  are  the  affections  known 
as  typhlitis,  c  e  c  i  t  i  s .  stercoral  typhlitis,  tuphlo-en- 
t  e  r  i  t  i  s,  and  their  ilk?  All  these  names,  so  well  known  of  old,  have  vanished, 
and  in  their  stead  appendicitis  appears. 

The  typhlon,  or  cecum,  was  the  organ  persistently  accused  in  all  right  iliac 
inflammatory  diseases  for  over  half  a  century,  whence  the  still  too  frequent  mis- 
nomer "perityphlitis."  The  first  step  toward  a  clear  understanding 
of  the  truth  was  the  establishment  of  two  sets  of  diseases  in  clinical  nosology; 
one  being  the  acute  and  perforative  forms  of  inflammation,  which  were  attrib- 
uted to  the  appendix,  the  other  the  slow-forming,  indolent  swellings,  laid  to 
the  account  of  the  cecum.  Aggressive  surgery  next  made  it  plain  that  the 
appendix  was  the  cause  of  the  latter  affections  as  well  as  of  the  former,  and, 
finally,  to-day,  the  question  is  seriously  raised  whether  the  cecum  is  ever  the 
seat  of  primary  inflammatory  lesions,  aside  from  those  occasioned  by  such 
specific  infection  as  tuberculosis,  cancer,   typhoid  fever,  and  lues. 

By  typhlitis  is  understood  a  localized  inflammatory  affection  of  the 
cecum,  beginning  in  the  mucosa  and  going  on,  it  may  be,  to  ulceration  and 
perforation.  A  typhlitis  secondary  to  an  appendicitis  is  not  rare,  and  it  may 
also  exist  as  a  part  of  a  dysenteric  inflammation  of  the  colic  tract.  Prim  a  r  y 
typhlitis,  however,  is  among  the  rarest  of  diseases,  al- 
though as  has  been  pointed  out,  an  inflammation  of  the  appendix,  resulting 
in  perforating  ulcer  of  the  cecum  through  continuity  of  tissue,  may  be  wrongly 
interpreted  as  primary  disease  of  the  cecum.     (Chap.  XII,  p.  277.)     The  long 


186  TYPHLITIS. 

cherished  opinion  thai  the  cecum  was  liable  to  an  inflammatory  affection  pecu- 
liar to  itself  and  possessing  certain  characteristic  signs  musl  be  definitely  aban- 
doned.  Never  again  will  the  cecum  be  reinstated  in  its  former  nosological  impor- 
tance. Affections  of  the  cecum,  as  Nothnagel  says,  are  identical  with  those 
of  other  portions  of  the  intestinal  tract,  and  if  in  some  instances  an  inflamma- 
tion, an  ulcer,  and  a  perforation  arc  found  in  it,  it  is  not  because  there  exists 
a  special  predilection  for  this  locality;  their  occurrence  there  is  merely  acci- 
dental, and  the  peculiarities  of  the  ease  are  those  imposed  by  the  anatomic 
relations  of  the  bowel.  Strumpell  (Lehrb.,  1899)  declared  thai  "typhlitis 
had  never  been  demonstrated  anatomically." 

In  the  hope  of  setting  this  old  hut  important  question  at  rest,  I  will  adduce 
such  facts  as  have  come  to  my  notice  in  the  literature  of  the  subject. 

In  the  first  place,  there  are  three  possible  conditions  to  be  borne  in  mind 
in  investigating  the  relations  of  inflammatory  diseases  of  the  cecum  to  those 
of  the  appendix : 

1.  A  n  ul  c  e  rati  o  n  of  t  h  e  a  p  p  e  ndi  x  m  ay  in  vol  v  e  t  h  e 
cecum   either   by  continuity  or  by  contiguity. 

2.  An  ulcer  in  the  appendix  may  exist  at  the  same 
t  i  m  e  a  s  a  n  u  1  c  e  r  in  t  h  e  c  e  c  u  m,  o  ne  be  i  n  g  e  n  t  i  r  e  1  y  s  e  pa  - 
rate    from    the    other. 

'A.  I  n  f  1  a  m  in  a  t  i  o  n  o  r  u  1  c  e  r  a  t  i  o  n  m  ay  exist  in  the 
ce  c  u  in    alone. 

An  inflammation  of  the  cecum  associated  with  a  sloughing  appendix  and 
advancing  to  ulceration  and  gangrene,  is  by  no  means  uncommon  in  neglected 
cases  of  appendicitis,  or  in  the  fulminating  form:  so  common,  indeed,  is  this 
direct  extension  of  the  disease  from  the  base  of  the  appendix  by  con- 
tinuity that  it  is  not  worthwhile  to  collect  cases  to  prove  what  forms  a 
part  of  the  experience  of  every  active  operator.  This  group  of  cases,  however, 
is  well  worth  a  separate,  careful  anatomico-pathologic  study. 

The  involvement  of  the  cecum,  by  extension  of  the  sloughing  process  from 
some  point  in  the  appendix  beyond  its  base  to  the  contiguous  cecum, 
i  only  found  in  cases  where  the  appendix  is  anatomically  disposed  close  to  the 
side  of.  or  behind  the  cecum,  being  often  plastered  down  to  it  by  old  inflamma- 
tion. Instances  of  this  condition  are  not  rare,  and  I  cite  one  given  by  Miss 
Gordon  (" L'Appendicite  chez  I'enfant,"  Th&se  <!<■  Paris,  1893). 

A  boy,  eight  years  old.  had  characteristic  symptoms  of  appendicitis,  and,  on 
operation,  a  localized  abscess  was  opened.  letting  out  fetid  sero-pus.  He  died  with 
a  creptitanl  edema  of  the  right  thoracic  wall,  extending  up  to  the  shoulder-blade. 
At  the  autopsy  there  was  no  peritonitis,  but  a  perforation  of  the  cecum  as  large 
as  a  one  franc  piece  was  found  on  its  posterior  external  surface,  in  contact  with 
gangrenous  tissues  at  the  extremity  of  the  appendix,  whose  remaining  portion 
adhered  to  the  cecum.  The  abdominal  muscles  were  infiltrated  with  pus  and  gas 
bubbles. 


PRIMARY    ULCERATION    OF   THE    CECUM.  487 

Another  interesting  case  of  this  kind,  reported  by  Fenger,  is  given  else- 
where.    (See  Chap.  XXV,  p.  590.) 

The  practical  importance  of  recognizing  this  group  of  cases  in  which  infec- 
tion proceeds  by  contiguity,  lies  in  the  fact  that  it  maybe  possible  for 
the  surgeon  to  prevent  such  an  occurrence  as  a  post-operative  perforation  of 
the  cecum  by  using  extreme  care  in  detaching  an  adherent  appendix  from  the 
colon,  as  well  as  by  suturing  carefully  the  torn  muscular  coat  of  the  cecum. 
In  many  instances  it  is  better  to  strip  the  mucosa  out  of  the  external  muscu- 
lar coats  of  the  appendix  rather  than  to  attempt  to  detach  the  entire  organ. 
(See  Chap.  XXV,  p.  .~>7u.) 

Ulcer  of  the  a  p  p  e  n  d  i  x  c  o  i  n  c  i  d  e  n  t  with  ulcer  of  the 
c  e  c  u  m  is  a  rare  occurrence,  in  which  the  colic  affection  is  probably  secondary 
to  that  of  the  appendix,  except  when  it  is  due  to  typhoid  fever.  Miss  Gordon 
(loc.  cit.)  cites  a  case  in  which  there  was  an  ulcerative  affection  in  the  appendix, 
complicated  by  an  ulcer  in  the  cecum,  the  two  being  anatomically  separated. 

A  child,  eight  years  old,  was  taken  ill  with  all  the  classical  symptoms  of  ap- 
pendicitis, and  a  hard  mass  on  the  right  side  could  be  felt  through  the  rectum. 
After  four  days'  delay  the  peritoneal  cavity  was  opened,  and  found  healthy,  but 
on  pulling  away  the  attached  omentum,  pus  escaped  from  a  perforation  in  the  mesen- 
tery at  the  ileocecal  angle.  The  appendix,  which  was  8  cm.  in  length,  was  found 
divided  3  cm.  from  its  base,  while  posterior  to,  and  to  the  outside  of  it,  near  its 
insertion,  there  was  a  perforation  of  the  cecum.  In  spite  of  drainage,  the  little 
patient  died  in  two  days  of  general  peritonitis. 

The  third  of  the  possible  contingencies,  namely,  the  possibility  of  inf  1  a  m- 
m  a  t  i  o  n  or  ulceration  of  the  c  e  c  u  m  in  the  a  b  s  e  n  c  e  of 
any  disease  of  the  appendix,  constitutes  the  real  crux  of  the  ques- 
tion. Were  we  to  draw  our  statistics  in  regard  to  it  from  the  older  records,  the 
condition  would  not  appear  so  infrequent;  ulceration  of  the  head  of  the  cecum 
with  perforation  was  then  often  noted,  but  in  these  statements  the  appendix  is 
either  not  mentioned  at  all,  or  it  is  significantly  stated  that  it  was  involved  in 
the  sphacelation;  our  present  knowledge  enables  us  to  read  plainly  between  the 
lines,  that  in  everyone  of  these  instances  there  must  have  been  a  gangrenous 
process  originating  in  the  appendix  and  extending  by  continuity  into  the  adja- 
cent cecal  wall.  Matterstock  (Handb.  d.  Kinderkr.,  1880,  Bd.  4,  Abth.  2.  p. 
903)  says  that  out  of  49  cases  of  "perityphlitis,"  one  or  more  perforations  of 
the  appendix  were  found  in  37,  and  in  this  number  lie  cites  4  cases  taken  from 
literature  dating  from  L853  to  1SS0,  in  which  it  is  stated  that  the  cecum  was 
perforated,  but  in  none  of  them  is  the  condition  of  the  appendix  mentioned. 
No  case  can  be  accepted  as  one  of  primary  disease  of 
t  li  e  cecum  in  which  it  is  not  also  definitely  stated 
that    the    appendix    was   examined    and    found   healthy. 

Renvers,  of  the  Moabit  Hospital  (quoted  by  Sonnenburg),  says  that,  leaving 


4SS  TYPHLITIS. 

out  of  consideration  the  more  frequent  carcinomatous  and  actinomycotic  tumors, 
as  well  as  tubercular  and  typhoid  ulcers,  ulceration  may  occur  on  the  posterior 
wall  of  the  cecum  in  association  with  fecal  accumulations.  Twice  lie  lias  himself 
seen  pressure  necrosis  of  thiskiml;  once,  due  to  a  co|>rolith  tlie  size  of  a  pigeon's 
egg,  held   fast    in  a  cecal  pocket,  and  once,  caused   by  a  fecal  concretion,  which 

formed  in  the  cecum  about  a  gall-stone  the  size  of  a  walnut.     It  may,  perhaps, 

be  asserted  without  fear  of  contradiction  that  ulceration  of  the  cecum  never 
occurs  simply  as  the  result   of  fecal  stasis  in  the  cecum. 

Out  of  600  operations  (autopsies  in  vivo)  on  patients  with  symptoms  of  "  typh- 
litis," SONNENBURG  found  but  a  single  instance  in  which  the  disease  was  pri- 
mary in  the  cecum,  and  that  was  an  inflammatory  affection  of  the  mucosa  (Peri- 
typhlitis, Leipzig,  L800,  p.  10). 

An  instance  of  simple,  localized,  primary  typhlitis  is  given  in  Jordan's  case 

(Archiv  /.  klin.  Chir.,  Bd.  1,  p.  534  >,  in  which  there  was  an  exact  microscopic 
examination  of  the  cecal  wall  during  or  soon  after  the  attack,  in  addition  to 
the  necessary  definite  statement   as  to  the  normal  condition  of  the  appendix. 

A  girl,  ten  years  old,  was  taken  ill  witli  typhlitis  (Blinddarrnentzimdung),  with 
fever  and  pain;  in  a  short  time  a  growing  exudate,  a  hand's  breadth  in  size,  ami 
painful  on  pressure,  appeared  in  the  cecal  wall.  The  exudate  could  also  he  felt 
through  the  rectum.  The  abdomen  was  not  distended  or  sensitive,  the  inflam- 
mation was  localized,  and  there  were  no  symptoms  of  any  serious  general  prostra- 
tion. Although  there  was  some  diminution  in  the  induration,  and  the  general 
condition  was  good,  obstipation  continued,  and  there  were  pains  in  the  cecal  region 
when  the  bowels  moved.  The  diagnosis  was  made  of  an  acute  appendicitis  in  the 
.stage  of  diminution,  with  perhaps  an  appendix  containing  pus  and  imbedded  in 
lymph,  and  six  weeks  after  the  onsel  an  operation  was  performed.  An  incision 
was  made  above  Poupart's  ligament,  and  the  cecum  discovered  in  the  midst  of  in- 
flammatory adhesions  of  the  small  intestines.  After  separating  the  adhesions, 
t  h  e  v  e  r  m  i  for  m  a  p  p  e  n  d  i  x  w  a  s  f  o  u  n  d  f  r  e  e ,  w  i  t  h  s  m  o  o  t  h  in- 
tact surface.  It  was  removed  and  proved  normal,  except  for  a  fecal  con- 
cretion the  size  of  a  pea.  After  freeing  the  cecum,  a  brawny  area  of  infiltration 
corresponding  to  the  intestinal  adhesions  on  the  anterior  wall,  and  the  size  of  a 
two-mark  (fifty-cent)  piece,  0.5  cm.  thick,  was  found  and  excised.  The  healthy 
edges  of  tin1  wound  were  then  united  with  silk  sutures.  The  resected  area  lay 
below  the  level  of  the  ileum,  and  about  0.5  (an.  to  the  outside  of  the  base  of  the 
resected  appendix.  The  abdomen  was  closed  with  drainage,  and  a  rapid  recovers 
ensued.  The  piece  of  cecal  wall  removed  was  '■'>  by  -  cm.  in  size,  and  on  its  mucous 
surface  there  was  a  superficial  ulcer  2.5  cm.  in  length  and  0.5  cm.  in  maximum 
breadth;  the  surrounding  mucosa  was  swollen.  Microscopic  examination  showed 
no  evidences  of  tuberculosis,  but  an  extensive  small-celled  infiltration,  most  marked 
in  the  mucosa  and  submucosa.  In  the  infiltration  zone,  staphylococci 
were  seen.  The  case,  therefore,  presented  a  simple,  primary,  acute  typhlitis  with- 
out perforation,  which  in  its  clinical  course  as  well  as  in  its  anatomic  details  corre- 
sponds to  the  classical  picture  of  a  stercoral  typhlitis. 


PRIMARY    ULCERATION    OF    CECI    \I.  489 

Other  cases  are  as  follows: 

1.  L.  S.  McMukthy  {Jour.  Amer.  Mai.  Assoc,  1888,  vol.  2,  p.  9).     A  young 

man  had  suffered  from  colic  for  several  months,  and  in  the  last  attack  he  had  in- 
tense pain  in  the  right  iliac  fossa  and  in  the  head  of  the  penis.  His  general  con- 
dition improved  under  sedative  treatment,  but  at  the  end  of  a  week  there  was  in- 
creased soreness  over  the  iliac  region,  and  five  days  later  a  slight  induration  could  be 
detected  there,  with  dulness  on  percussion.  This  induration  increased  until  it  formed 
an  oblong  sausage-shaped  tumor.  On  the  sixteenth  day  a  hemorrhage  from  the 
bowels  occurred,  with  hiccough,  tympanites,  and  vomiting,  when  a  diagnosis  of 
cecal  inflammation  was  made.  Symptoms  of  collapse  supervened,  and  an 
immediate  operation  was  advised,  under  the  impression  that  there  must  be 
a  perforation  of  the  vermiform  appendix.  An  incision  three  inches  long,  made 
over  the  tumor,  revealed  a  limited  peritonitis,  and  a  normal  appendix.  On  the 
anterior  and  external  surface  of  the  cecum  two  gangrenous  perforations  were 
found,  one  about  2  cm.  and  the  other  1  cm.  in  diameter.  The  edges  of  these 
perforations  were  trimmed  with  scissors  and  the  openings  closed  with  silk  sutures. 
The  abdominal  cavity  was  then  carefully  cleansed  and  1  he  wound  dressed;  imme- 
diate improvement  ushered  in  complete  recovery. 

2.  J.  B.  Murphy  (Jour.  Amer.  Med.  Assoc,  March,  1894,  Case  125).  A  man, 
twenty-four  years  old.  had  suffered  for  ten  weeks  with  severe  pain  uniformly  dis- 
tributed over  the  abdomen,  accompanied  by  tumefaction,  tympanites,  and  pain 
in  micturition.  The  temperature  reached  101°  F.  and  the  pulse  104.  There  was 
diarrhea  during  the  entire  illness,  with  bloody  stools  during  the  last  five  days.  An 
exploratory  laparotomy  was  made,  when  half  a  pint  of  pus  escaped,  together  with 
a  piece  of  necrotic  tissue  three  inches  long.  The  cavity  looked  like  that  of  a  diph- 
theritic abscess.  The  patient's  condition  grew  worse,  and  he  died  within  twenty- 
four  hours,  when  an  autopsy  showed  that  the  incision  had  passed  directly  into 
the  cecum,  and  the  appendix  was  not  affected  in  any  way;  the  mucous  membrane 
of  the  colon  was  gangrenous  and  detached  from  the  submucosa. 

3.  J.  D.  Rushmore  (Ann.  Surg.,  1894,  vol.  19,  p.  577).  A  man,  age  no1  given, 
had  three  or  four  attacks  of  pain  in  the  region  of  the  appendix  with  fever,  lasting 
a  week  or  ten  days  each  time,  and  recurring  at  intervals  of  a  few  months.  In  the 
last  fatal  attack  the  patient  was  up  and  about  the  day  before  dysenteric  symp- 
toms supervened.  The  autopsy  showed  an  enormous  collection  of  pus,  which  had 
burrowed  down  under  the  rectum,  giving  rise  to  the  tenesmus  and  bloody  discharges. 
The  abscess  had  perforated  the  head  of  the  colon,  apparently  from  without  inward, 
reversing  the  picture  of  a  perforating  typhoid  ulcer,  the  opening  through  the  peri- 
toneal coat  being  much  larger  than  that  in  the  mucous  coat.  The  appendix  was 
to  all  appearance  healthy,  but  it  was  not  subjected  to  a  microscopic  examination. 

4.  M.  F.  Porter  (Med.  News,  1895,  vol.  (17.  p.  299).  No  history  could  lie  ob- 
tained. A  man,  who  was  thought  to  have  appendicitis,  refused  operation  and  died 
a  few  days  later.  The  autopsy  showed  a  healthy  appendix,  while  the  upper  part 
of  the  cecum  and  seven  or  eight  inches  of  the  ascending  colon  were  gangrenous. 

5.  C.  Beck  (Ncic  York  Med.  Jour..  July,  1898,  Case  9).  A  man.  aged  forty. 
began  to  have  intense  pain  in  the  umbilical  region  and  in  the  right  iliac  fossa,  ac- 
companied with  nausea  and  vomiting.     He  was  up  and  about,  however,  for  ten 


490  TYPHLITIS. 

days,  when  he  was  admitted  to  the  hospital  in  a  septic  condition,  with  a  small  pulse, 
high  temperature,  tumefaction,  and  corresponding  dulness  in  the  right  iliac  fossa. 
Operation  revealed  partial  gangrene  of  the  cecum,  bu1  the  appendix  was  nol  found. 
The  illness  continued,  and  repeated  abscesses  formed  in  the  intestinal  loops  around 
the  cecum.  An  ectropion  of  the  bowel  as  large  as  the  palm  of  the  hand  appeared, 
but  closed  again  when  a  small  abscess  under  the  liver  was  opened.  Three  weeks 
after  the  first  operation,  enteroplasty  was  performed.  On  separating  the  adhe- 
sions in  the  intestines,  a  perfectly  intact  appendix  with  a  healthy  mucosa  was  found. 
It  may  be  assumed,  therefore,  thai  the  gangrenous  process  was  at  firsl  confined 
to  the  wall  of  the  cecum. 

ti.  1'.  A.  Soi  ["ham  (Brit.  Med.  .Jm,,-..  1898,  vol.  '_'.  p.  1130).  A  man,  aged 
twenty-nine,  was  admitted  to  the  hospital  with  symptoms  of  an  acute  appendic- 
itis of  four  days'  duration.  There  was  distinct  fulness  above  the  outer  part  of 
Poupart's  ligament,  tenderness  on  pressure,  and  slight  dulness  on  percussion,  with 
rigidity  of  the  abdominal  muscles  on  the  same  side,  and  some  tympanites.  The 
temperature  was  only  99.4°  F.  <  >n  the  ninth  day  the  temperature  was  normal. 
the  patient  was  up  and  appeared  to  be  doing  well,  when  vomiting  sot  in,  which 
shortly  became  fecal.  An  exploratory  laparotomy  was  dune  on  the  eleventh  day. 
and  an  incision  made  over  the  region  of  the  appendix,  letting  <mt  a  small  quantity 

nt   [Mis.  which  contained  a  fecal  C •retinn    formed  about  a  pin,  the  head  and  point 

of  which  protruded.  The  localized  abscess  was  then  washed  out  with  a  boric  acid 
solution,  and  a  drainage-tube  inserted,  after  which  the  patienl  recovered,  except 
that  a  fecal  fistula  remained.  About  two  months  after  leaving  the  hospital  he  was 
re-admitted,  as  the  fistula  showed  no  signs  of  closing:  at  the  second  operation 
the  wound  was  enlarged  and  found  to  open  directly  into  the  cecum,  which  was 
adherent  to  the  abdominal  walls:  the  opening,  about  2  cm.  in  diameter,  was 
in  the  anterior  wall  of  the  bowel,  about  .">  cm.  from  t lie  insertion  of  the  appen- 
dix, which  was  healthy  and  free  from  adhesions.  The  protruding  cecal  mucosa 
was  reduced  and  the  opening  closed  after  liberating    the  margin,  when  recovery 

follow  I'd. 

7.  Southam  {ibid.).  A  boy  of  nineteen  was  admitted  to  the  hospital  with  a 
fecal  fistula  in  the  right  groin,  about  1  inch  above  the  centre  of  Poupart's  ligament. 
He  had  had  an  abscess  in  this  situation  about  si\  months  before,  with  the  usual 
symptoms  of  a  "perityphlitis";  this  was  followed  by  a  fistulous  opening.  After 
an  ineffectual  attempt  to  close  it  by  scraping,  the  opening  was  enlarged,  and  the 
fistula  traced  to  its  connection  with  the  bowel,  which  was  found  on  the  anterior 
wall  of  the  cecum,  close  to  its  junction  with  the  ileum.  The  appendix  was  quite 
healthy.  It  was  impossible  to  free  the  margin  of  the  opening  sufficiently  to  permit 
a  plastic  operation,  therefore  an  ileo-colostomy  was  performed,  and  a  drainage- 
tube  inserted  into  the  wound,  after  which  the  patient  made  a  good  recovery. 

8  SOTTTHAM  (ibid.).  A  man.  sixty-seven  years  old.  was  admitted  to  the  hos- 
pital with  symptoms  of  incomplete  obstruction,  beginning  seven  weeks  before. 
He  had  considerable  abdominal  distention,  but  nothing  was  perceptible  to  palpa- 
tion. Four  days  after  admission  he  was  suddenly  seized  with  a  severe  chill,  and 
the  temperature,  previously  normal,  rose  to  103°  F.  He  recovered  from  the  rigor. 
but  the  same  evening  complained  of  great  pain  in  the  right  iliac  fossa,  went  into 


PRIMARY    ULCERATION   OF   CECUM.  491 

collap.se,  and  died  in  two  hours.  The  autopsy  revealed  a  peritoneal  cavity  con- 
taining pus  and  fluid  feces,  most  abundant  in  the  neighborhood  of  the  right  iliac 
fossa.  The  upper  part  of  the  rectum,  the  colon,  the  cecum,  and  the  small  intestine 
for  some  distance,  were  distended  with  masses  of  hardened  feces.  Behind  the 
cecum  were  a  number  of  old  adhesions  bounding  an  irregular  abscess  cavity  containing 
pus  mixed  with  fecal  matter,  and  communicating  with  the  general  peritoneal  cavity. 
On  opening  the  cecum,  a  superficial  ulcer,  about  3  cm.  in  diameter,  involving  only 
the  mucous  membrane,  was  found  on  the  posterior  wall,  and  at  the  centre  of  the 
ulcer  there  was  a  small  perforation  about  the  size  of  a  pea,  opening  into  the  ab- 
scess.    The  appendix  and  other  parts  of  the  intestines,  small  and  large,  were  healthy. 

9.  Sonnenbttrg  (Perityphlitis,  1900.  p.  13).  A  seamstress,  twenty-two  years 
old,  had  gradually  increasing  and  finally  violent  pain  in  the  right  lower  abdomen, 
without  vomiting  or  fever;  she  had  never  had  a  previous  attack,  but  had  recently 
suffered  from  constipation.  The  abdomen  was  sensitive  at  all  points,  especially 
in  the  pit  of  the  stomach  and  in  the  right  iliac  fossa,  where  there  was  a  definite. 
diffused  area  of  resistance  without  any  defined  boundaries.  There  was  moderate 
dulness  and  no  tympany,  (in  opening  the  abdomen  the  peritoneum  was  found 
thickened  and  attached  to  a  portion  of  the  cecum,  the  rest  of  which  was  normal; 
the  appendix  was  free,  movable,  and  normal.  The  diseased  portion  of  the  cecum, 
which  was  lanrer  than  a  dollar  (iiber  funfmarkstuck  <jross)  and  sharply  defined  from 
the  surrounding  healthy  tissue,  was  excised.  The  adjacent  portion  of  the  bowel  was 
found  lined  with  normal  mucosa.  The  wound  was  closed,  a  drainage-tube  inserted, 
and  the  patient  recovered.  Microscopic  examination  of  the  excised  tissue  showed 
a  uniform  cellular  infiltration  of  all  the  coats,  but  no  carcinoma,  syphilis,  or  tuber- 
culosis. Sonnenbuhg  could  think  of  no  cause  for  such  a  peculiar  localized  affec- 
tion other  than  that  this  portion  of  the  bowel  must  have  been  incarcerated  in  one 
of  the  neighboring  retro-peritoneal  pockets,  bringing  about  such  characteristic 
changes  as  are  commonly  noted  in  a  chronically  inflamed  hernia  of  the  intestinal 
wall." 

10.  Gordon  (Joe.  cit.).  A  little  girl,  eleven  years  old,  had  a  lumbar  trauma- 
tism, failing  on  a  piece  of  furniture  and  at  once  complaining  of  pain,  which  soon 
passed  away.  Five  days  later  she  had  violent  pain  in  the  right  side  of  the  abdomen 
without  vomiting,  but  with  a  little  fever,  and  constipation.  There  was  no  definable 
mass.  An  iliac  incision  evacuated  about  a  wineglassful  of  fetid  pus,  but  she  died 
of  general  peritonitis,  when  at  the  autopsy  a  fecal  calculus  about  the  >ize  of  a  date- 
seed,  was  found  below  and  to  the  outside  of  the  cecum.  Miss  GORDON  states  that 
the  appendix  was  not  perforated,  but  that  there  was  a  perforation  of  the  cecum 
to  the  inner  side  of  the  appendix  from  1'  to  :'>  mm.  in  diameter. 

11.  Vox  Eiselsbebg  (Archiv  f.  klin.  Chir.,  1898,  Bd.  ">6.  p.  309).  The  pa- 
tient suffered  from  violent  attacks  of  abdominal  pain  with  exacerbations  of  fever. 
On  opening  the  abdomen  the  small  intestines  were  found  extensively  adherent 
among  themselves  in  the  neighborhood  of  the  cecum,  while  the  cecum  itself  was 
united  with  the  right  ovary  into  a  rigid,  densely  adherent  tumor.  The  appen- 
dix was  easily  removed,  but  it  was  inpossible  to  extirpate  the  cecum,  largely  on 
account  of  the  risk  to  the  ureter.  The  case  was  then  treated  by  dividing  the  cecum 
at  the  lower  level  of  the  cecal  valve  and  closing  the  distal  portion  of  the  bowel  by 


492  TYPHLITIS. 

continuous  sutures  in  two  rows.  The  lower  part  of  the  bowel  and  the  entire  cecum 
were  closed  down  i"  a  small  fistulous  orifice  which  was  left  open  for  an  iodoform 
drain.  At  first  there  was  a  free  purulent  secretion  from  the  excluded  cecum,  with- 
out, of  course,  any  fecal  material.  After  three  weeks  the  discharge  had  greatly 
diminished,  so  that  the  patient  was  able  to  leave  the  hospital  thirty  days  after  the 
operation,  free  from  pain.  The  cecal  tumor  could  not.  at  that  time,  he  felt.  five 
months  later  she  returned,  complaining  that  numerous  ligatures  were  coming 
through  the  fistula.  An  anesthetic  was  then  given  and  the  entire  area  curetted, 
alter  which  she  recovered  entirely. 

12.  Meusseb  [Mitt.  a.  d.  Grenzgeb.  d.  Mai.  u.  Chir.,  1M>7,  Bd.  2.  p.  :«>7).  The 
patient,  a  girl  seventeen  years  old.  had  had  a  "typhlitis"  in  her  ninth  year,  lasting 
five  weeks.  In  her  sixteenth  year  she  had  another  attack  with  high  fever,  tympany, 
great  sensitiveness  in  the  region  of  the  cecum,  and  vesical  disturbance,  lasting 
three  weeks.  Fourteen  days  before  she  entered  the  clinic  she  had  a  third  attack. 
IIm-  ileocecal  region  was  then  very  sensitive  to  pressure.  At  the  operation  adhe- 
sions of  the  cecum  to  the  anterior  and  lateral  abdominal  walls  were  found,  as  well 
as  adhesions  of  the  omentum  to  the  colon  and  gall-bladder.  The  appendix  was 
thin,  1)  cm.  in  length,  and  hung  down  into  the  true  pelvis;  it  appeared  normal,  ex- 
cept for  a  few-  fecal  fragments.  The  adhesions  of  the  intestines  were  loosened, 
lmt  the  appendix  was  not   removed. 

The  following  additional  case  is  of  interest,  although  it  cannot,  I  think,  be 
admitted  to  the  category  of  primary  cecal  affections,  as  daily  experience  shows 
that  the  appendix  can  recover  perfectly  after  a  violent  attack  of  inflammation. 
The  evidence  would  be  stronger  if  the  appendix  had  been  removed  and  examined 
microscopically  for  remains  of  an  old  attack,  more  apt  to  be  found  on  its 
mucous  surface. 

Schlafke  (Munch,  med.  Wochenschr.,  1895,  Bd.  42.  pp.  22.  753).  A  young 
man  had  had  an  attack  of  colicky  pain  a  half-year  before  he  was  first  seen.  Celi- 
otomy was  performed,  and  on  the  under  surface  of  the  cecum  a  number  of  delicate 
cord-like  adhesions  were  found,  which  connected  it  on  the  outer  side  and  below 
to  the  parietal  peritoneum.  The  appendix,  which  lay  to  the  outside  of  the  cecum, 
was  very  long,  movable,  and  showed  no  abnormal  conditions;  it  was  not  removed, 
therefore,  although  the  adhesions  of  the  cecum  were  loosened. 

Prom  these  cases  it  is  evident  that  a  localized  inflammatory  disease  of  the 
cecum,  when  it  occurs.  i<  usually  mistaken  for  disease  of  the  appendix.  I  believe. 
however,  that  a  presumptive  diagnosis  could  be  made  in  some  cases,  if  the  onset  of 
the  attack  were  carefully  observed,  it'  the  local  physical  signs  were  minutely  noted 
from  day  to  day,  and,  above  all.  if  sufficient  importance  were  attached  to  the 
condition  of  the  bowels.  It  will  be  seen  by  consulting  the  scanty  information 
afforded  in  these  records,  that  diarrhea,  dysentery,  and  hemorrhage  were  promi- 
nent features  in  several  of  the  cases.     There  is  no  differential  sign  by  which  we 


TREATMENT.  -i'X', 

can  distinguish  a  case  in  which  a  pin  perforates  the  cecum,  from  one  in  which 
it  perforates  the  vermiform  appendix.    A  foreign  body,  such  as  a  large  coprolith, 

might  be  felt  by  careful  palpation,  if  the  abdominal  walls  were  thin;   foreign 
bodies  might  also  be  revealed  by  the  X-ray  skiagraph. 

Celiotomy,  in  accordance  with  the  indications  given  in  the  section  on 
treatment  (see  Chap.  XXV),  is  the  proper  treatment,  whether  the  disease  is 
confined  to  the  cecum  or  includes  the  appendix.  An  alisccss  should  be  opened 
and  drained;  at  a  later  date  the  bowel  can  be  exposed  and  liberated,  and  the 
fistulous  orifice  excised  and  closed.  If  it  fortunately  happens,  as  in  the  McMrirruv 
case,  that  it  is  possible  to  expose  the  openings  in  the  bowel  in  such  a  way  that 
they  can  be  treated  and  sutured  at  once,  this  is  manifestly  the  best  plan,  saving 
a  tedious  convalescence.  Care  must  be  taken,  in  such  a  case,  to  cut  well  out 
into  the  sound  tissues  of  the  bowel  beyond  all  suspicion  of  disease,  looking 
out  for  gangrene  and  undermining  of  the  mucosa.  The  best  treatment  of  ulcer- 
ated areas,  threatening  to  break  through  the  external  coat  of  the  intestine, 
would  probably  be  by  infolding  the  bowel  at  those  points,  using  one  or  two 
layers  of  sutures.  A  loose  drain  should  always  be  left  in  place  for  several 
days,  in  case  the  sutures  do  not  hold.  In  Jordan's  case  the  ulcer  was  resected 
with  success. 


CHAPTER  XXII. 
GENERAL  CONSIDERATIONS  REGARDING  OPERATION. 

INTRODUCTORY.     INDICATIONS  FOR  OPERATION.     IMMEDIATE  OPERATION. 

INTERMEDIATE  OPERATION.     LATE  OPERATION. 

INTERVAL  OPERATION. 

INTRODUCTORY. 
Relations  Between  Physician  and  Surgeon.— Although  appendicitis  is  now 
generally  reckoned  a  surgical  affection,  and  a  familiarity  with  its  symptoms  lias 
now  become  so  common  that  the  patient  himself  will  often  send  al  once  for  a 
surgeon,  the  disease  is  still  in  most  instances  first  seen  by  the  medical  man, 
summoned  under  the  impression  that  the  attack  is  one  of  simple  colic,  due 
perhaps  to  indigestion.  The  relations  between  the  physician  and  the  surgeon 
become,  therefore,  a  matter  of  importance,  for  while  it  is  generally  conceded 
that  as  soon  as  an  appendicitis  is  found  to  be  actively  progressive  a  surgeon  ought 
to  be  called,  it  is  not  always  understood  that  he  is  not  summoned  merely  because 
his  knowledge  of  anatomy  enables  him  to  find  and  remove  the  diseased  organ, 
but  rather  because  of  his  greater  diagnostic  skill  in  surgical  affections,  and  his 
more  extensive  knowledge  of  their  natural  history,  which  cause  him  to  realize 
more  fully  the  dangers  attending  each  step  in  the  progress  of  the  disease;  he 
is  better  able,  therefore,  to  decide  upon  the  best  time  to  operate,  since  the  family 
physician  has  not  always  a  keen  appreciation  of  those  conditions  in  which  a 
grave  prognosis  would  at  once  lie  given  by  an  experienced  surgeon.    Too  often, 

however,  in  spite  of  the  multiplied  experiences  of  the  last  fifteen  years,  does 
the  surgeon  still  have  reason  to  lament  the  fact  that  patients  who  have  been  first 
in  the  hands  of  his  medical  confrere  are  recommended  to  seek  the  aid  of  surgery 
only  when  the  conviction  is  overwhelming  that  an  operation  is  imperative, 
and  at  a  date  too  late  for  him  to  act  with  any  reasonable  assurance  of  success. 

My  attention  has  been  specially  directed  by  J.  E.  STOKES  to  the  fact  that  this 
happy-go-lucky  procrastination  is  notably  the  habit  in  remote  rural  and  moun- 
tainous districts,  where  a  consultation  is  often  sought  only  in  extremis.  But  even 
in  our  large  cities  and  hospitals,  in  communities  where  both  the  medical  period- 
icals and  'he  constant  discussions  of  our  societies  conspire  to  teach  men  better, 
the  surgeon  often  has  just  reason  for  complaint  that  he  is  not  given  a  better 
chance  to  demonstrate  the  safety  of  operative  procedures  under  suitable  condi- 
tions. The  duty  of  a  physician  is  aptly  expressed  in  YV.  W.  Keen's  aphorism, 
"The    first    indication    in    appendicitis    is    to    call    in    a 

404 


REMOVAL   OF   NORMAL   APPENDIX.  495 

it  is  the  office  of  the  surgeon  to  determine  upon  the  necessity 
for  an  operation,  and  for  this  reason  he  should  be  asked,  at  the  very  outset,  to 
see  the  case  in  consultation  with  the  physician. 

Alter  the  surgeon  has  been  summoned,  the  question  may  arise:  What  is 
his  dutv  when  operation  is  advised  by  him  and  refused  by  the  patient  or  his 
relatives?  In  a  case  of  well-defined  appendicitis  with  persistent  symptoms  of 
a  severe  type,  the  proper  and  dignified  course  is  to  retire  from  the  case;  but  if 
the  surgeon  dues  this,  he  should  carefully  state  that  it  is  because  he  is  unwilling 
to  stand  by,  able  to  relieve  and  yet  helplessly  watching  the  patient  who  is  taking 
such  desperate  chances.  He  ought,  as  he  withdraws,  to  make  it  plain  that 
it  is  always  within  the  limits  of  possibility,  even  if  it  is  highly  improbable,  that 
a  desperate  case  may  recover  without  operation.  If  he  abandons  the  case  with 
the  unqualified  statement  that  the  patient  will  surely  die  without  operation, 
and  recovery,  as  has  often  happened,  takes  place,  nothing  will  hurt  his  reputation 
so  greatly,  and,  what  is  of  far  greater  importance,  other  sufferers,  also  urgently 
in  need  of  surgical  aid,  will  be  encouraged  to  take  their  chances  without  it,  under 
the  impression  that  his  art  is  mere  guesswork.  No  blame,  however,  for  lack 
of  dignity,  but  rather  praise,  should  be  given  to  the  professional  man  who, 
although  his  urgent  advice  is  not  taken,  nevertheless,  from  a  sense  of  duty, 
and  with  the  assurance  that  he  has  not  in  any  degree  lost  the  confidence  of  the 
family,  continues  to  watch  over  the  helpless  sufferer  as  he  battles  for  life,  with 
faithful,  tender  care,  exhausting  every  palliative  resource,  even  to  the  fatal 
end. 

On  the  other  hand,  the  surgeon  called  in  late  to  save  a  desperate  case,  ought 
never,  for  a  moment,  to  consider  his  own  reputation  and  the  probable  fatal  out- 
come, but  should  a  ways  be  ready  to  give  the  patient,  who  is  usually  the  in- 
nocent victim  of  circumstances,  the  slender  chance  held  out  by  an  operation.  He 
should  feel  that,  under  these  circumstances,  he  is  rendering  a  valuable  service, 
if  he  saves  but  one  life  in  fifty,  when  death  is  certain  without  his  intervention. 

Removal  of  the  Normal  Appendix  and  the  Incidental  Removal  of  the 
Appendix. — Before  discussing  the  special  indications  for  operation,  it  is  I 
think,  worth  while  to  consider  certain  circumstances  in  general,  under  which 
removal  of  the  appendix  may  be  necessary  or  advisable. 

1.  Routine  removal  of  the  normal  appendix  as  a  prophylactic  measure. 

2.  Removal  of  the  normal,  or  the  adherent  appendix,  whenever  the 
opportunity  is  afforded  incidentally  to  do  so  with  safety. 

.Should  the  normal  appendix  lie  removed  as  a 
p  r  o  p  hylactic  m  e  a  s  u  r  e  ?  Under  the  caption  "normal  prophylactic 
appendectomy"  the  question  has  actually  been  debated  "whether  the  appendix 
should  be  removed  in  children  as  a  matter  of  routine,  in  order  to  insure  them 
against  appendicitis.  "  This  question  was  answered,  and  seriously  discussed  by  88 
American  surgeons  (St.  Loui*  Med.  Rcr.,  March  17,  1000).  It  is  sufficient  to 
declare    that   the  proposition  was    regarded   almost    unanimously  as  "absurd," 


49G  GENERAL   CONSIDERATIONS   REGARDING   OPERATION. 

"unjustifiable,"  "unsurgical,"  or  "without  excuse.''  The  mere  entertainment  of 
such  a  suggestion  is  evidence  of  a  state  of  public  hysteria,  induced  by  the  often 
sudden  and  alarming  onset  of  the  disea.-e.  as  well  as  by  the  increasing  frequency 
m!  operations  for  its  relief;  but,  more  than  all,  perhaps,  is  it  the  fruit  of  constant 

discussion  and  fomentation  of  the  subject  by  the  laity,  and  by  the  daily  press; 
all  of  which  factors  combine  to  bring  about  a  state  of  panic-stricken  uncertainty 
when   each  man   feels   that    he   may   lie   the   next  victim.      Should  appendicitis 

become  still  mure  frequent  than  at  present,  this  question  may  again  be  pro- 
pounded, when  the  following  data  have  been  secured :  first,  the  actual  pro  mille 
risk  to  each  individual  that  he  will  have  the  disease;  second,  the  proportion 
of  fatal  and  non-fatal  cases,  when  the  disease  is  let  alone;  third,  the  pro  mille 
risk  from  the  operation  itself. 

S  h  o  u  1  d  the  n  0  r  in  a  1 ,  or  t  h  e  a  d  h  e  r  e  n  t  a  p  p  e  n  d  i  x,  he 
r  e  m  o  v  e  d  w  hene  ver  the  o  p  p  o  r  t  u  n  i  t  y  is  i  n  <•  iden  1  all  y 
a  f  f  or  d  e  d  1)  y  a  c  e  1  i  o  t  o  m  y  u  n  d  e  r  t  a  k  e  n  f  o  r  o  t h e  r  a  f  f  e  <•- 
t  i  o  n  s  ?  In  urgent  and  desperate  cases  of  abdominal  surgery  it  is  clear  that 
no  additional  operation  is  justifiable.  The  question  whether  the  appendix, 
normal  or  adherent,  should  he  removed  in  simple  and  uncomplicated  cases  is 
niie  attended  with  so  much  interest  that  I  have  been  at  some  pains  to  ascer- 
tain the  sentiment  of  the  profession  in  America  in  regard  to  it.  Fuller  data 
will  lie  found  elsewhere  (see  Chap.  XXIX);  T  here  note  simply  thai  4-1  sur- 
geons consulted  were  against  removing  the  appendix  under  the  conditions 
stated,  while  26  were  in  favor  of  doing  so.  To  the  second  question,  namely, 
the  propriety  of  removing  the  adherent  appendix,  66  surgeons  replied  in  the 
affirmative,  while  7  gave  a  negative  answer.  My  own  opinion  agrees  with  the 
majority  in  both  instances,  and  my  reasons  are  given  as  cited  elsewhere. 


INDICATIONS  FOR  OPERATION. 
The  operator  in  appendicitis  must  always  be  on  his  guard  lest  he  open 
the  abdomen  only  to  find  there  is  no  disease  at  all,  or.  perhaps,  a  morbid  con- 
dition entirely  unconnected  with  the  appendix,  such  as  intestinal  ob- 
struct i  o n  .  an  ileus,  a  movable  kidney,  agall-bladd  e  r 
filled  with  stones,  a  p  yo-salpinx,  an  o  v  a  r  i  a  n  tumor, 
or  an  e  x  t  r  a  -  u  t  e  r  i  n  e  p  r  e  g  n  a  n  c  y  .  An  error  in  diagnosis  is  not  so 
serious  when  there  exists  a  surgical  affection  in  itself  demanding  operation, 
fur  the  harm  then  done  is  limited  to  the  additional  incision  needed  to  reach 
the  unsuspected  disease,  but  it  is  a  very  different  matter  when  the  malady  turns 
out  to  be  nothing  more  than  simple  colic  with  indigestion,  or  else  a  case  of 
"  p  er  i  t  onis  m"  (Guebler).  I  shall  never  forget  one  of  my  first  patients,  a 
young  woman  who  had  been  under  my  care  for  a  gonorrheal  salpingitis,  for  which 
I  had  done  a  radical  operation.  She  called  me  a  long  distance  from  home, 
one  Sunday  morning,  for  intense  lower  abdominal  pains,  and  I  distinctly  felt 


INDICATIONS    FOR   OPERATION.  \'.h 

an  exquisitely  sensitive,  nodular  mass,  behind  the  uterus.  I  opened  the  ab- 
domen with  the  hope  of  removing  the  focus  of  infection  and  nipping  an  acute 
peritonitis  in  the  bud,  but,  to  my  chagrin,  discovered  only  a  rectum  full  of 
beans,  eaten  at  a  late  supper  and  imperfectly  masticated. 

The  gr  o u  p  o  f  pos i  t i  v  e  s  y  m  p  t  o  m  s  w  h  i ch  t  h  e  s  u  r  g  eon 
m  u  s  t  keep  1>  e  f  o  r  e  him  as  i  n  dications  for  o  pe  r  a  t  i  o  n 
are  : 

Pain  about  the  umbilicus,  or  in  the  right  iliac  fossa. 

Muscle  spasm  over  the  affected  area. 

Tenderness,  evident  on  palpation. 

Localized    swelling. 

Nausea   or   vomiting. 

Constipation. 

Elevation  of  temperature. 

Increased    pulse-rate. 

Increasing  leucocytosis. 

Ileus. 

In  a  typical  case  all  these  symptoms  may  be  present,  but  the  surgeon  will 
often  be  called  upon  to  decide  for  or  against  an  operation  when  several  of  them 
are  absent;  for  example,  if  there  is  muscle  spasm  and  local  tenderness  with 
marked  and  increasing  leucocytosis.  or,  as  Robert  Abbe  puts  it,  "when  there 
is  tenderness  and  muscle  spasm  with  a  fairly  active  onset,"  an  operation  is 
imperative,  although  other  signs  are  absent.  A  well-developed  local  tenderness 
with  muscle  spasm,  and  a  pulse  increasing  in  rapidity  maybe  the  sole  symptom 
in  some  of  the  worst  forms  of  appendicitis  during  the  early  stages. 

Pain  . — Pain  may  lie  situated  in  any  part  of  the  abdomen  during  the  initial 
period  of  the  disease;  at  first  it  shows  a  striking  predilection  for  the  umbilical 
region,  but  a  little  later  it  settles  down  to  the  affected  area  in  the  right  iliac  fossa. 
After  the  pain  has  once  become  localized  in  the  iliac  region,  an  increase  in  its 
intensity  or  an  enlargement  of  its  boundaries  points  either  to  the  occurrence  of 
suppuration,  or  to  an  extension  of  the  disease  into  new  territory.  A  sudden 
cessation  of  pain  may  lie  due  to  the  rupture  of  an  abscess  into  the  bowel,  or. 
in  the  case  of  an  extensive  infection,  this  may  be  the  first  ominous  sign  of  col- 
lapse from  an  overwhelming  toxemia.  M.  H.  Richardsox  (Trans.  Amer. 
Sura.  Assoc,  1899)  says,  "If  pain  is  severe,  and  increasing  in  severity  after 
the  early  hours,  operation   is  demanded  by  this  symptom  alone." 

Tenderness. — Tenderness  on  pressure  together  with  pain  are  the 
symptoms  simulated  by  neurotic  patients  with  an  appendicito-phobia,  or  "ap- 
pendicitis on  the  brain"  (Osler).  The  surgeon  must  be  ever  on  the  watch 
to  detect  these  often  involuntary  malingerers  (sit  renin  verbo).  As  a  rule,  it 
is  easy  to  throw  them  off  their  guard  by  engaging  them  in  earnest  conversation 
while  examining  the  painful  area,  or  by  using  the  other  hand  simultaneously  upon 
some  otlvr  part  of  the  body  and  thus  confusing  the  attention.  It  is  a  good  prac- 
32 


498  GENERAL   CONSIDERATIONS    REGARDING    OPERATION. 

tice  to  begin  the  examination  by  palpating  other  parts  of  the  abdomen,  especially 
the  left  iliac  fossa,  and  so  securing  a  basis  of  comparison.  When  tenderm 
is  really  present,  il  constitutes  a  valuable  sign  indicative  of  an  underlying  in- 
flammatory process,  often  corresponding  to  the  area  outlined.  It  is  well  to 
test  the  tenderness  by  firsl  making  gentle,  graduated  pressure  with  all  four 
fingers,  and  then  outlining  the  ana  more  precisely  with  one  or  two.  Tender- 
ness confined  to  a  small  area  may  indicate  an  inflammation  limited  to  the 
immediate  neighborhood  of  the  appendix  or  an  intra-appendical  affection, 
ording  to  the  stage  of  the  disease.  Van  Lennep  reports  a  case  which  il- 
lustrates very  well  the  importance  of  tenderness  as  a  single  symptom  (Halm. 
Med.  Month..  Jan..  1895  : 

A  man,  forty-four  years  old,  wa>  taken  ill  with  appendicitis  presenting  very  mild 
symptoms.  These  increased  for  about  twelve  hours,  and  then  gradually  lessened 
for  aboul  five  days.  There  was  then  a  moderate  increase,  followed  by  a  diminu- 
tion of  even'  sign  except  tenderness.  On  account  of  this  symptom,  his  physician 
summoned  surgical  aid.     At  the  time  of  operation,  whicl  te  the  same  night, 

even-  symptom  was  practically  gone,  except  the  tenderness,  which  was  exquisite. 
An  incision  showed  an  entirely  unprotected  abscess,  while  the  appendix  was  injected 
and  gangrenous  in  several  -pots  and  surrounded  by  a  quantity  of  sero-pus. 

Rigidity. — Rigidity,  local,  in  the  early  stages  of  the  disease,  beet 
genera]  in  a  diffuse  peritonitis;  it  is  one  of  the  remarkable  efforts  ,,f  nature 
to  put  the  parts  at  rest  and  thus  limit  the  spread  of  an  infection.  When  pres- 
ent, it  constitutes  a  most  valuable  sign,  perhaps,  indeed,  the  one  sign  which 
comes  nearest  to  being  pathognomonic.  When  associated  with  localized  pain. 
fever,  and  a  rising  leucocytosis,  the  diagnosis  is  sufficiently  clear  to  demand 
operation.  Both  rigidity  and  tenderness,  however,  are  absent  in  some  of  the 
wore!  cases.  The  decision  to  employ  active  measures  must  then  depend  upon 
pain,  fever,  and  increasing  leucocytosis.  after  the  possibility  of  intra- 
thoracic disease  has  been  carefully  excluded.  Richardson  says:  "As  an  in- 
dication of  spreading  infection,  tenderness  rank-  with  pain  and  rigidity.  If 
these  symptoms  increase  in  extent,  the  infection  is  spreading,  when,  it  i-  need- 
less to  say,  immediate  intervention  is  required." 

Temperature. — Rise  of  temperature  is  a  most  variable  sign  in  a|>- 
pendicitis;  it  is  usually  elevated,  although  rarely  high,  and  occasionally  it 
i-  almost  normal  throughout  the  attack.  Fever,  in  combination  with  other 
signs,  constitutes  a  valuable  asset  in  the  diagnostic  complex,  but  in  some  of 
the  worsl  cases,  requiring  immediate  operation,  the  temperature  is  normal. 
We  may  have  fever  without  infection  in  hysteria,  and  (in  children)  with  a  trifling 
indigestion.  With  these  exceptions  the  presence  of  a  persistent  fever  is  jrener- 
ally  associated  with,  and  a  pretty  good  index  of  the  activity  of  the  inflam- 
matory process.     When,  therefore,  fever  i-  present  together  with  the  necessary 


INDICATIONS   FOR   OPERATION.  499 

local  signs,  the  operator  may  proceed  with  a  comfortable  assurance  that  the 
lesions  under  consideration  demand  surgical  interference. 

Pulse . — A  good  full  pulse  gives  a  better  prognosis  in  operation  than  a 
pulse  running  up  to  120  to  140,  and  small  in  volume.  If  a  pulse  which  has 
been  but  little  accelerated  begins  to  go  up  steadily  in  the  presence  of  other 
signs  of  disease,  a  speedy  operation  is  indicated. 

T  u  m  o  r . — This  is  the  result  of  adherent  intestines,  of  exudate,  or,  per- 
haps, of  an  abscess  with  rigidity  of  the  overlying  abdominal  wall.  Sometimes 
the  tumor  cannot  well  be  felt  because  of  this  rigidity,  and  an  anesthetic  is  neces- 
sary to  relieve  the  muscle  spasm,  and  enable  the  surgeon  to  outline  the  mass 
below.  Unless  all  the  symptoms  are  decidedly  improving,  the  presence  of 
a  tumor  is  an  indication  for  operation.  If  it  is  stationary  or  enlarging,  or 
if  there  are  signs  of  pus,  an  operation  ought  to  be  done  at  once. 

Vomi  tin  g.— Most  attacks  of  appendicitis  begin  with  vomiting,  but  if 
it  is  persistent,  and,  above  all,  if  it  is  associated  with  constipation,  distention, 
and  other  local  signs  of  appendicitis,  operation  is  urgent.  Later  on,  a  constant 
vomiting  and  retching  form  the  most  marked  signs  of  a  general  peritonitis, 
where  immediate  operation  is  the  only  hope. 

Leucocytosis . — As  an  aid  to  diagnosis  and  an  indication  for  opera- 
tion the  value  of  the  blood-count  depends  upon  the  stage  at  which  the  leuco- 
cytes are  counted.  Early  in  the  disease,  arising  leucocytosis  is 
an  indication  for  i  m  mediate  operation;  later  on,  when 
abscess  formation  has  begun,  no  reliance  can  be  placed  upon  the  leucocyte  count. 
At  this  stage  there  may  even  be  a  decrease.  The  variation  of  opinion  at  present 
found  among  physicians  as  to  the  importance  of  leucocytosis  as  a  guide  to 
operation  arises  from  the  fact  that  the  count  is  made  by  them  at  different 
periods.  Those  who  make  a  count  early  in  the  disease  find  in  it  a  reliable 
guide  and  praise  it  highly;  while  those  who  postpone  it  until  the  later  stages, 
derive  little  or  no  assistance  from  it.  and  consequently  deprecate  its  usefulness. 

Ileus. — Of  all  indications  for  operation  during  the  attack,  ileus,  unless 
of  the  most  transitory  character,  is,  as  Lennander  says,  one  of  the  most 
u  r  g  e  n  t .  It  may  arise  from  the  violence  of  the  attack,  or  it  may  I «'  occasioned 
by  the  peritonitis.  An  ileus  appearing  at  the  onset  may  disappear  after  the 
administration  of  a  little  opium;  when  persistent,  it  usually  arises  from  a  fixa- 
tion of  one  or  more  loops  of  bowel,  compressed  or  kinked  in  such  a  manner  as 
to  hinder  the  passage  of  gas  or  feces.  The  patient  vomits  constantly,  throwing 
off.  at  first,  the  contents  of  the  stomach,  and  afterward  fecal  matter.  After 
the  lower  bowel  is  emptied,  no  more  feces  pass,  unless  the  obstruction  is  only 
partial.  In  many  cases  these  symptoms  supervene  gradually,  and  the  obstruc- 
tion does  not  become  complete  for  some  days.  The  abdomen  swells,  at  first 
on  one  side,  or  in  the  median  line,  and  the  patient  is  tormented  with  paroxysmal 
pain  associated  with  periodical,  and  often  visible  contractions  of  the  proximal 
portion  of  the  ileum.     Under  these  circumstances,  operation  is  urgently  in- 


500  GENERAL   CONSIDERATIONS    REGARDING    OPERATION. 

dicated,  before  the  persistent  distressing  symptoms  have  depleted  the  vitality. 
Prompt  action  is  all  the  inert'  necessary  because  the  operation,  in  many  instances, 
proves  to  be  one  of  unusual  severity. 

Promptitude  in  Operation. — As  soon  as  operation  is  definitely  decided 
upon,  each  minute  of  delay  is  valuable  time  lost,  since  in  every  case  of  appen- 
dicitis there  is  a  moment  when  relief,  possible  before,  arrives  too  late;  and  as 
this  critical  period  draws  momentarily  nearer,  prompt  measures  must  be  taken 
in  anticipate  its  advent.  It  is  nol  always  the  medical  man  who  is  responsible 
for  injurious  delay  in  operation,  for  we  find,  to  our  surprise,  frequenl  reports 
of  cases  seen  by  eminent  and  experienced  surgeons,  who  have  countenanced 
a  delay  of  days,  or  even  weeks,  in  the  Eace  of  the  most  pronounced  symptoms 

of  the  disease,  such  as  extreme  pain  (quieted  by  opium),  continued  elevation 
of  temperature,  muscular  spasm,  and  well-defined  mass  in  the  right  iliac  fossa. 
It  is  distressing  to  bear  of  the  golden  moments  wasted  in  continued  efforts  to 
dissipate  these  symptoms  by  purgative  drugs.  It  would  he  invidious  to  select 
illustrative  instances,  here  and  there,  from  medical  literature;  it  is  enough 
to  sound  a  warning,  which  should  he  reiterated  until  it  is  effectually  dinned 
into  the  ears  of  each  rising  generation:  Our  trust  is  sacred,  and  whenever  we 
a— nine  the  responsibility  of  life  in  a  dangerous  case,  we  ought  to  act  with  the 
same  energy  and  promptitude  in  bringing  relief  and  in  forestalling  danger  as 
we  should  wish,  were  we  ourselves  the  patients.  I  do  not  desire  here  to  criti- 
cize the  attitude  of  those  members  of  the  profession  who  are  under  the  con- 
viction that  it  is  hotter  to  wait  until  the  affected  area  is  well  walled  off  from 
the  peritoneal  cavity,  hut  I  do  wish  to  protest  against  dawdling  when  the  neces- 
sity for  operation  is  clearly  recognized.  A  surgeon  watching  a  case  with  pro- 
gressive symptoms  day  after  day.  ought  to  experience  a  positive  sense  of  humilia- 
tion when  he  tardily  opens  an  abscess  and  lets  out  pus.  I  have  before  me  the  case 
of  a  poor  fellow,  twenty  days  in  the  hands  of  a  surgeon,  who  finally  naively 
remarked  that  "operation  now  became  imperative,  and  three  pints  of  pus  were 

evacuated  "  ! 

Every  surgeon  who  expects  to  he  called  on  to  operate  for  appendicitis  should 
keep  his  instruments  and  other  paraphernalia  in  readiness  to  he  transported  to  the 
patient  at  a  moment's  notice,  so  that  no  time  may  he  lost  in  sterilizing,  in 
collecting  necessary  articles,  or  in  packing.  A  nurse  with  experience  in  such 
cases  and  surgical  assistants  ought  always  to  he  available.  The  ques- 
tion of  personal  convenience  ought  not  to  he  con- 
sidered, and  the  night  should  he  regarded  as  the  day. 
Two  distressing  experience-  due  to  delay  are  frankly  related  by  Tufpieh  (R<  v. 
de  chir.,  1895,  p.  7()">>  as  a  warning  to  the  man  who  lets  convenience,  com- 
fort, or  engagements  delay  an  operation.  In  one.  a  patient  with  an  acute 
appendicitis  refused  operation;  later  in  the  day  the  pain  increased,  and  when 
seen  next  morning  by  ToFFTER,  he  was  found  with  a  peritonitis  characterized 
by  a  dissociation  between   pulse  and   temperature;    the  operation   was    then 


PROMPTITUDE    IN   OPERATION.  501 

planned  for  five  o'clock  in  the  afternoon,  but  when  the  hour  arrived,  the  patient 
was  dead.  The  second  case  was  that  of  a  child  who  had  been  ill  for  three  days. 
The  next  day  was  fixed  for  the  operation,  but  at  the  appointed  time  the  child 
was  moribund. 

A  n  o t  h  e r  s  o u r  c e  of  fatal  d  e 1  a  y  m a  y  b e  the  d  e s  i r < 
the  patient,  or  the  relatives,  to  await  the  a  r  r  i  v  a  1  of 
in  embers  of  the  family  f  r  o  m  a  d  i  s  t  a  nee.  If  the  surgeon  is 
convinced  that  an  operation  is  imperative,  he  mast  not  sacrifice  the  ad  van  tag 
of  time  to  sentiment,  but  must  assume  the  added  responsibility  of  urging,  and 
even  insisting  upon  instant  action.  The  evils  of  procrastination  are  well  shown 
in  a  case  reported  by  Carmalt  {Amer.  Jour.  Med.  Sri.,  .bin..  1894  : 

The  patient,  a  college  student,  was  under  the  immediate  care  of  another  physi- 
cian; the  initial  constitutional  symptoms  were  severe,  but  the  local  evidences  of 
appendicitis  were  not  marked.  His  home  was  at  a  distance,  and  word  was  re- 
ceived that  his  father  was  hastening  on,  accompanied  by  his  own  surgeon.  From 
a  natural  wish  not  to  seem  precipitate,  the  operation  was  postponed  until  such 
serious  symptoms  arose  that  further  delay  was  out  of  the  question;  it  was  then 
done  without  the  father's  presence.  Unfortunately  the  eighteen  hours'  delay  had 
carried  the  patient  beyond  the  safe  period,  and  a  general  septic  peritonitis  had 
arisen  from  the  rupture  of  a  thin-walled  abscess,  associated  with  a  gangrenous 
appendix  containing  a  fecal  concretion. 

A  common  idea,  prevalent  even  among  the  medical  profession,  is  that  the 
patient  is  too  weak  to  stand  operation  in  an  acute  stage;  the  notion  also  pre- 
vails in  some  quarters  that  hot  weather  drains  the  strength,  and  therefore  is 
a  contraindication  to  active  measures.  These  factors,  although  undoubtedly 
deleterious,  need  not  hinder  prompt  operation  in  urgent  cases. 

It  may  be  positively  stated  that  no  case  of  appendicitis  where  an  operation 
was  neces<aIy  was  ever  operated  upon  too  soon,  and  when  the  deci- 
sion to  operate  is  made,  no  consideration,  h  o  w  ever 
plausible,  should  be  admitted  as  a  r  e  a  s  o  n  f  o  r  u  n  - 
necessar  y  del  a  y. 

Operations  for  appendicitis  classified  according  to  the  stage  of  the  disease 
at  which  they  are  performed  are  four  in  number,  namely,  early  opera- 
tion, performed  at  the  very  outset;  intermediate  operation. 
performed  from  the  second  to  the  fifth  days;  late  operation,  performed 
after  sufficient  time  has  elapsed  for  the  formation  of  an  abscess;  and  in- 
terval operation,    performed   between  the  attacks. 

Early  Operation. — By  early  operation  we  mean  one  in  which  the  progress 
of  the  disease  is  arrested  by  surgery  before  the  occurrence  of  various  untoward 
complications,  such  as  peritonitis,  septicemia,  pylephlebi- 
tis, etc.  The  cases  which  die  in  the  hands  of  a  good  surgeon  are  those  with 
complications,  death  being  due   to  exhaustion,   sepsis,   injury  to   the  bowel, 


502  GENERAL    CONSIDERATIONS    REGARDING    OPERATION. 

extensive  adhesive  peritonitis,  abscesses  formed  elsewhere  in  the  peritoneum, 
above  the  liver,  or  in  the  pleura.  These  complications  arise  in  the  course  of 
the  disease  and  are  not  present  al  the  outset.  An  operation  done  in  the  initial 
stages  encounters  none  of  these  risks  and  is  as  safe,  or  almost  as  safe,  as  an  in- 
terval operation.  To  put  the  matter  a  little  differently,  it  is  clear  that  in  every 
appendicitis,  no  matter  how  desperate,  there  existed  a1  one  time,  early  in  the 
history,  a  stage  in  which  it  could  be  treated  without  risk  to  life,  and  no  sur- 
geon ever  yet  saw  a  bail  case  in  which  lie  did  not  regret  his  inability  to  operate 
under  conditions  antecedent  by  some  weeks,  days,  or  even  hours. 

The  opinion  of  American  surgeons  from  the  first  has  been  that  early  opera- 
tion is  the  only  safe  plan,  and  many  of  the  best  French  surgeons  now  take 
the  same  position.  The  attitude  of  most  of  the  Germans,  on  the  other  hand, 
is  more  conservative  and  strongly  in  favor  of  delay,  a  point  of  view  in  which 
the  English  surgeons,  to  a  large  extent,  agree.  The  diversity  of  opinion'  between 
American  and  German  surgeons  as  to  what  constitutes  "an  early  operation'' 
is  nowhere  more  apparent  than  in  Borxhaupt's  able  paper  entitled  "Zur 
Friihoperation  der  Appendicitis"  (Langeribeck's  Arch.  j.  Klin.  Chir.,  1903,  Bd. 
70,  p.  300),  in  which  v.  Bergmann's  cases  are  discussed.  He  says,  in  speak- 
ing of  early  operations  in  Germany:  "We  divide  the  cases  into  two  categories.  To 
the  first  group  belong  1()_>,  in  which  there  was  an  encapsulated  abscess;  to  the 
second  group  we  assign  those  in  which  a  general  peritonitis  was  found."  He 
adds,  farther  on,  "of  an  early  operation  in  the  restricted  sense  of  the  word 
we  cannot  speak,  as  the  earliest  was  after  fifty-seven  hours." 

The  ideal  time  In  r  o  p  emtio  n  i  n  a  c  u  t  e  a  ppendicitis 
is  within  the  first  few  hours,  and  not  later  than  the  first  twenty- 
four,  when  the  organ  can  be  readily  detached  from  the  surrounding  structures, 
and  before  the  formation  of  an  exudation  or  of  an  abscess  with  adhesions  among 
the  bowels.  If  a  patient  with  a  frank,  well-defined  appendicitis  is  seen  at  the 
very  outset  of  the  attack,  he  has  a  better  chance,  if  a  good  surgeon  is  avail- 
able, by  immediate  operation  than  by  waiting.  If,  however,  the  surgical  skill 
at  command  is  not  all  that  could  be  desired,  he  will  do  better  to  take  the  chances 
of  a  spontaneous  cure,  or  to  wait  for  the  formation  of  a  localized  abscess,  which 
can  be  opened  and  drained  later  on. 

Another  argument  for  immediate  operation  is  the  fact  that  the  disease  has 
already  seated  itself  in  the  appendix  ami  made  definite  progress — who  can  say 
how  far? — before  giving  rise  to  the  first  recognizable  symptom.  Also,  as 
W.  II.  Doughty  of  Augusta,  (la.,  insists,  acute  cases  almost  always  carry  with 
them  the  signs  of  antecedent  disease,  SO  that  we  are  dealing  either  with  a  recur- 
rence or  with  the  culmination  of  a  pathologic  process,  which,  in  most  cases 
has  only  jusl  reached  tin'  point  of  involving  the  peritoneum,  through  which  it 
makes  it -elf  known. 

It  must  always  be  remembered  that  in  the  present  condition  of  our  knowl- 
edge it  is  impossible  to  estimate  how  rapid  the  progress  of  an  appendicitis 


EARLY    OPERATION.  503 

will  be.  In  one  case  of  Finney's,  a  hospital  nurse  was  seized  with  her  first 
attack  of  pain  shortly  after  coining  on  duty  in  the  morning,  and  the  opera- 
tion, performed  within  three  hours  of  the  apparent  onset,  showed  the  appendix 
gangrenous  on  one  side  and  ready  to  perforate.  In  another  case  <if  the  same 
surgeon's,  the  patient,  a  young  physician,  operated  upon  within  six  hours  of 
the  initial  complaint,  was  found  to  have  a  spreading  peritonitis,  and  there 
was  every  reason  to  believe  that  the  very  first  pain  he  felt  was  occasioned  by 
the  perforation;  both  cases  recovered: 

The  advantages  of  early  operation  may  be  summed  up  as  follows: 

It  is  safest,  because  it  can  never  he  foreseen  which  cases  will  go  on 
to  suppuration  and  which  will  not;  moreover,  fatal  complications  may  arise 
at  any  moment,  absolutely  without  warning. 

The  operation  is  more  easily  do  n  e ,  for  there  are  no  fresh 
adhesions,  or,  if  there  are,  they  are  not  dense;  there  is  often  no  extra-appen- 
dical  pus,  and  the  appendix  is  more  easily  reached  than  it  can  be  at  a  later 
stage  through  adherent,  matted  intestines. 

The  patient  is  spared  days  of  suffering,  for  the  attack, 
being  cut  short,  is  reduced  to  a  brief  surgical  illness  with  rapid  recovery,  instead 
of  a  protracted  convalescence  of  weeks  or  months.  The  patient  is  also  saved 
the  pain  which  inevitably  attends  the  changing  of  the  gauze  dressings  necessary 
when  drainage  is  employed. 

The  liability  to  recurrent  attacks  is  obviated,  and 
this  is  not  always  the  case  in  later  operations,  for  the  longer  the  delay,  the  less 
the  likelihood  that  the  surgeon  will  find  and  remove  the  appendix.  It  must 
always  be  remembered  that  recovery  from  the  attack  does  not  always  mean 
recovery  from  the  disease.  Recovery  from  the  attack  may  take  place  under 
conservative  treatment:  recovery  from  the  disease,  as  a  rule,  is  certain  only 
when  the  appendix  has  been  removed. 

A  n  e  a  r 1 y  o  p  e  r a  t  i  o  n  obviates  the  risk  of  h e r  n  i  a , 
which  is  so  common  in  suppurative  cases. 


INTERMEDIATE  OPERATION. 
When  the  patient  is  first  seen  on.  say,  the  second  to  the  fifth  day  of  a 
frank  appendicitis,  the  question  of  operation  becomes  more  complex.  At  this 
period  the  surgeon  has  to  consider  the  difficulties  and  dangers  of  breaking 
up  adhesions,  together  with  the  associated  risk  of  distributing  a  localized  in- 
fection, and  some  operators  regard  these  as  so  great  that  they  prefer  to  wait 
until  a  later  period,  in  the  hope  that  the  disease  will  either  abate  and  be  ab- 
sorbed, or  else  that  a  well-defined  abscess  may  be  evacuated  without  danger, 
the  case  being  watched  meantime  from  hour  to  hour.  There  is  no  class  of  ca-<es 
which  present  such  difficulty  to  the  conscientious  surgeon  as  these,  which  we 
may,  for  convenience  of  discussion,  divide  into  three  classes: 


504  GENERAL   CONSIDERATIONS    REGARDING    OPERATION. 

1.  C  as  e  s  w  h  i  c  li  a  r  e  m  a  a  i  f  es  1 1  y  g  e  1 1  i  n  g  w  o  r  s  e,  as  evi- 
denced by  continued  local  pain,  swelling,  tenderness,  muscle  spasm,  and  increas- 
ing elevation  of  temperature,  with  quickened  pulse.  These  symptoms,  together 
with  the  facial  expression,  make  up  a  tout  ensemble  which  the  experienced  eye 
quickly  recognizes.  My  colleague,  W.  S.  Halsted,  tersely  says,  "if  a  case 
is  on  the  rise,  operate;  if  it  is  on  the  fall,  you  may  wail;  if  a  case  is  falling 
hut  not  last  enough,  one  is  prone  to  operate  to  relieve  anxiety."  1  think  that 
all  surgeons  will  agree  with  the  first  part  of  this  statement. 

2.  ('  a  s  e  s  i  n  w  h  i  c  h  t  h  e  patient,  although  nut  gr  o  w  i  n  g 
worse,  is  tint  distinctly  improving,  and  there  arc  sufficient 
signs  of  activity  t"  suggesl  the  possibility  of  latent  trouble,  should  he  operated 
upon  at  ciiicc.     Must  surgeons,  I  think,  will  agree  to  this. 

3.  C  a  s  c  s  w  h  i  c  h  a  r  e  u  n  d  <>  u  h  tedl  y  o  n  t  h  e  in  e  n  d  .  as  shown 
by  improvement  in  the  general  condition  of  the  patient,  the  occurrence  of  free 
evacuations  from  the  bowels,  and  decreasing  tympany,  together  with  lcssen- 
ing  of  muscle  spasm  over  the  affected  area,  lowering  of  temperature  and  pulse- 
rate,  and  a  decrease  in  the  leucocyte  count.  It  is  of  the  utmost  importance 
to  remember  in  such  cases  that  the  most  marked  signs  of  improvement  may 
he  entirely  illusory,  and  the  surgeon  must  he  on  his  guard  against  misinterpret- 
ing that  commonly  observed,  hut  dangerous  lull  in  the  symptoms,  that  so  often 
precedes  another  outbreak  of  pus  or  the  occurrence  of  general  peritonitis.  There 
is  a  large  group  of  cases  in  which,  as  JaCOBSON  says.  "<  here  may  he  a 
mitigation  of  all,  and  a  complete  disappearance  of 
most  of  the  symptoms,  and  yet,  during  the  period  of 
their  subsidence,  the  diseased  process  has  gone  on 
-  t  e  a  d  i  1  y."  A  good  illustration  of  such  a  case  is  given  by  Cordieh  (Jour. 
Amer.  Med.  Assoc.,  Feb.  22,  L896): 

A  girl  of  sixteen  was  seized  with  intense  pain  in  the  right  iliac  fossa,  followed 
by  shock,  from  which,  however,  she  rallied;  later  the  pain  spread  over  the  entire 
abdomen,  hut  subsided  in  eighteen  hours.  When  Men  by  the  surgeon,  her  pulse 
was  '.'ii.  and  her  temperature  100.9°  1  . :  she  complained  of  a  sense  of  distention, 
but  no  pain.  She  was  bright  and  cheerful,  and  insisted  on  getting  out  of  bed  to 
have  her  picture  taken,  so  that  she  was  standing  upright  not  half  an  hour  before 
the  operation.  This  was  performed  two  days  after  the  first  symptom-  made  their 
appearance,  and  showed  a  diffuse  septic  peritonitis,  while  the  intestines  were  as 
lifeless  as  a   rubber  hose.     Death   took  place  shortly  after. 

Tt  will  lie  seen  that  the  really  difficult  cases  in  the  intermediate  class  belong 
in  this  division,  and  any  satisfactory  conclusion  in  regard  to  them  can  lie  readied 
only  by  a  process  of  elimination.  If  the  patient  is  in  the  country,  and  the  sur- 
geon i-  obliged  to  return  to  town,  it  is  safer  to  operate  than  to  leave  him  under  cir- 
cumstances where  he  cannot  command  the  surgeon's  services  should  he  sud- 
denly require  them.     If  the  patient  is  so  situated  that  he  can  obtain  surgical 


INTERMEDIATE    OPERATION.  505 

aid  at  once  in  ease  of  necessity,  it  is  safe  to  wait,  supposing  lie  is  kept  under 
hourly  observation,  and  provided  the  discretion  of  the  physician  and  the  intelli- 
gence of  the  patient  can  be  depended  upon,  especially  if  the  attack  is  not  a. 
first  one.  But  if  the  physician's  judgment  or  the  patient's  intelligence  is  below 
par.  it  is  safer  to  operate  than  to  take  the  chances  involved  in  waiting  under 
such  conditions. 

Again,  if  the  patient  is  in  a  hospital,  it  is  safe  to  wait  and  watch,  when  it 
would  not  he  so  in  a  private  house,  because  he  is  under  incessant  skilled  observa- 
tion and  a  surgeon  can  be  secured,  if  he  is  needed,  without  delay.  Even  these  condi- 
tions, however,  cannot  guarantee  safety,  as  shown  by  the  fact  that  in  two  or  three 
cases  at  the  Johns  Hopkins  Hospital  perforation  occurred  under  the  eyes  of 
skilled  professional  attendants,  and  operation  revealed  a  spreading  peritonitis. 
If  the  physician  has  no  surgical  experience,  and  a  good  surgeon  cannot  be  had, 
the  patient  will  stand  a  better  chance  without  operation,  or  at  least  by  holding 
off  until  a  well-defined  abscess  has  formed.  The  same  rule  holds  good  for  a 
surgeon  with  but  little  experience,  although  with  improved  manual  dexterity, 
a  better  knowledge  of  the  disease,  of  the  methods  of  handling  infected  tissues 
so  as  not  to  spread  the  infection,  ami.  above  all,  of  drainage,  the  same  man 
will  find  that  he  can  give  the  patient  a  better  chance  of  recovery  by  removing 
the  Jons  et  origo  mali  than  by  leaving  it  to  nature,  that  is  to  say,  to  blind  chance. 
Urgent  personal  reasons  for  delay  may  be  admitted  in  cases  of  the  kind  under 
discussion,  where  they  would  be  excluded  in  others.  It  may  be  added  that, 
as  Fixxey  says,  the  surgeon  himself  is  never  so  unhappy  as  when  he  is  watch- 
ing an  appendicitis  which  has  not  been  operated  upon. 

Some  of  our  best  surgeons  are  of  opinion,  however,  that  operation  is  indicated 
under  all  circumstances.  Abbe,  while  dwelling  upon  the  necessity  for  formu- 
lating two  sets  of  rules,  one  for  the  surgeon  and  another  for  the  attending  phy- 
sician, says  that  "when  the  diagnosis  is  made  is  the  time  to  operate,  for  there 
is  no  case  of  appendicitis  which  can  be  trusted,  no  matter  how  simple  the  symp- 
toms seem  to  be,  and  even  in  the  absence  of  fever,  quickened  pulse,  difficult 
respiration,  or  leucocytosis."  Richardson  also  finds  himself  more  and  more 
inclined  to  operate  at  any  stage  of  the  disease,  no  matter  when  it  is  detected. 
Finally,  I  wish  to  emphasize  the  statement  that  no  hard-and-fast  rule  should 
be  laid  down  as  regards  operation  in  this  class  of  cases.  Just  as  it  has  wrought 
much  harm  to  hold  '"the  interval"  as  the  ideal  time  for  removal  of  the  appen- 
dix, thus  inducing  men  to  try  to  tide  over  an  acute  attack  in  order  to  reach  this 
desirable  period,  so  in  like  manner  does  the  prevailing  idea  as  to  a  so-called 
"twenty-four  hour  period"  often  work  detrimentally  by  conveying  the  im- 
pression that  no  serious  lesion  or  extension  of  the  disease  can  take  place  within 
the  first  twenty-four  hours,  when  there  is  abundant  evidence  to  the  contrary. 
If  we  must  fix  a  date,  it  would  be  better  to  establish  a  two-hour  rule,  and  call 
two  hours  the  safe  period,  the  preparations  to  operate  being  hastened  in  the 
meantime.     Each  case  must  be  a  law  unto  itself,  and  it  is  as  dangerous  to  gener- 


506  GENERAL   CONSIDERATIONS    REGARDING   OPERATION. 

alize  here  as  it  would  be  in  plastic  surgery  to  fit  a  particular  pattern  to  every  case; 
moreover,  a  rule  which  is  good  for  an  experienced  surgeon  is  dangerous  for  one 
with  little  or  no  experience.  As  a  matter  of  fact,  must  surgeons,  even  the  besi . 
are  guided  in  their  conduct  toward  any  individual  case  by  their  personal  expe- 
rience in  the  immediate  past,  thus  demonstrating  their  fallibility  of  judgment 
and  lack  of  precision  in  a  matter  where  the  reverse  is  of  so  much  importance. 


LATE  OPERATION. 

A  late  operation,  as  has  been  said,  is  one  performed 
after  the  formation  of  a  well-defined  a  lis  cess  shut 
o  f  f  1)  y  a  d  hes  i  o  ns;  o  r  els  e  u  n  d  e  r  t  a  k  e  n  f  o  r  a  s  p  r  e  a  d  i  n  g 
peritonitis.  Although  the  operation  for  an  abscess  (suppurative  peri- 
appendicitis) is  often  a  simple  and  a  safe  procedure,  it  is  never  the  pro- 
cedure of  election  on  the  part  of  a  good  surgeon,  on 
account  of  the  risks  of  peritonitis  incurred  in  the  delay.  FlNNEY  says:  "The 
presence  of  pus  in  an  appendicitis  case  is  prima  fade  evidence  of  a  mistake  on 
the  part  of  somebody,  the  patient,  the  physician,  or  the  surgeon.  If,  how- 
ever, a  -killed  surgeon  is  not  available  in  the  early  stage  of  the  disease,  tic 
patient  will  run  less  risk  from  delay,  and  the  subsequent  incision  of  an  abscess, 
than  from  a  clumsy  operation." 


INTERVAL  OPERATION. 

It  is  most  important  to  have  a  clear  understanding  as  to  what  is  meant  by 
the  term  "interval  operation."  Many  lives  have  been  risked, 
and  not  a  few  lost,  t  h  r  o  u  g  h  a  misunderstand!  n  g  a  ml 
a  misuse  of  this  expression.  E.  M  Pond,  of  Rutland,  Yt.. 
expresses  this  point  in  a  clear  and  practical  way  while  speaking  of  his  own 
clientele  in  a  personal  communication:  "One  of  the  worst  features  that  I  have 
to  contend  with  is  the  idea  that  many  have  regarding  interval  operations:  the 
symptoms  of  the  disease  appear  to  them  so  mild  that  they  take  the  chances 
of  recovery.  You  might  he  surprised  if  you  knew  the  number  of  deaths  due 
to  delay  on  this  account  in  this  section  of  country.  I  am  positive  that  the 
teaching-  of  those  who  advocate  interval  operations  account  for  many  deaths 
from  appendicitis.  I  mean  by  this  that  the  majority  of  general  practitioners 
are  unable  to  discriminate  between  those  cases  that  should  have  an  immediate 
operation  and  those  that  mighl  be  delayed,  consequently  they  remind  you  that 
'B. waits  for  the  interval.'" 

The  term  interval  operation  is.  strictly  speaking,  a  misnomer, 
as  the  second  attack,  or  that  which  is  to  follow  the  period  of  quiescence,  is 
always  a  hypothetical  one.  The  interval  operation  depends  for  its  raison  d'itre 
upon  the  reasonableness  of  the  presumption  that  a  patient  who  has  had  one 


INTERVAL   OPERATION.  507 

or  more  well-defined  attacks  of  appendicitis  will,  in  all  likelihood,  suffer  from 
a  repetition;  it  should  be  clearly  undersl I  that  in  using  the  expression  ''in- 
terval operation"  there  is  no  implied  argument  that  a  patient  suffering  from 
an  appendicitis  should  risk  his  life  by  deliberately  waiting  until  the  attack  is 
past  to  have  his  appendix  removed  "in  the  interval."  The  interval 
operation  is  not  for  the  acute  sufferer,  but  for  him 
w  ho  has  passed  thr  o  ugh  one  o  r  more  a  t  t  a  cks,  a  n  d  f  o  r 
t  li  i  s  reason  decides  to  submit  to  the  operation  w  h  i  1  e 
enjoying  a p  p a  r  e n  t  h e  a  1 1  h ,  r  a  t  h e  r  t  h  a  n  incur  the  risk 
of  another,  possibly  fatal  attack.  The  cogent  reason  for  per- 
forming an  operation  in  the  interval  of  quiescence  lies  in  the  fact  that  the  risk 
to  life  incurred  by  operating  in  the  course  of  an  attack  of  appendicitis  is  vastly 
greater  than  the  risk  incurred  in  doing  so  after  all  the  symptoms  have  subsided. 
During  this  period  of  complete  defervescence  the  ri-k  is  almost,  some  operators 
claim  quite,  nil.  Lexxaxder  operated  on  271  cases  without  a  death.  The 
French  surgeons  have  appropriately  distinguished  between  operations  performed 
during  the  height  of  the  disease,  often  marked  by  febrile  disturbances,  which 
they  call  operations  a  chaud,  and  those  performed  after  the  attack  has  sub- 
sided, to  which  they  apply  the  suitable  term  operations  a  jroid,  a  term  for 
which  there  is  no  English  equivalent.  The  true  purpose  of  the  interval 
operation  is  well  expressed  by  the  phrase  "prophylactic  appendectomy"  (Vig- 
xard). 

An  interval  operation,  therefore,  is  one  in  which  the  operation  is  under- 
taken after  the  subsidence  of  the  general  and  local  symptoms.  The  patient 
is  free  from  fever,  his  functions  are  normal,  he  has  recovered  his  appetite,  and 
feels  able  to  resume  his  usual  occupations,  there  is  little  or  no  pain,  the  ab- 
domen is  no  longer  distended,  there  is  no  spasm  of  the  muscle,  tendernes-  is 
not  market  1,  and  there  is  no  mass.  And  yet  (I  would  emphasize  this  fact) 
these  signs  of  a  restitutio  ad  integrum,  both  general  and  local,  satisfactory  as  they 
may  seem  to  be,  do  not  define  with  sufficient  precision  the  proper  time  for  an 
interval  operation.  It  is  most  important  not  to  operate 
until  at  least  several  weeks  have  elapsed  since  the 
acute,  severe  attack  has  subsided.  Surgeons  who  operate 
too  early  in  the  interval  have  in  numerous  instances  opened  up  small  con- 
cealed pockets  of  pus,  full  of  organism-  still  retaining  an  enhanced  virulence,  by 
which  they  have  inoculated  the  peritoneum  and  destroyed  their  patients,  in  spite 
of  abundant  drainage.  This  error  is  most  apt  to  occur  where  there  is  a  little  re- 
sidual abscess  at  the  end  of  an  appendix  hanging  down  into  the  pelvis.  It  is  better 
to  keep  the  patient  under  observation,  and  to  wait  from  four  to  six  weeks,  or 
longer.  We  must  distinguish  clinically  between  an  interval  operation  in  an  ap- 
parent subsidence  of  all  symptoms,  with  no  tangible  evidence  of  lingering  disease, 
and  an  operation  undertaken  for  the  sequelae  of  an  appendicitis,  when  a  residual 
abscess  can  be  plainly  felt.     This  distinction  will  often  rest  upon  the  accidental 


."it  IN  GENERAL   CONSIDERATIONS    REGARDING   OPERATION. 

position  of  a  chronically  inflamed  appendix,  which  in  one  case  is  easily  accessible, 
and  in  another  lies  out  of  roach  in  the  pelvis. 


DESPERATE  CASES. 

The  question  must  sometimes  arise  as  to  the  surgeon's  duty  in  those  eases 
which  he  first  sees  in  extremis.  Under  these  conditions  the  sole  consideration 
with  tire  operator  .should  be  the  possibility  of  saving  life,  and  the  experience  of 
the  best  surgeons  shows  conclusively  that  this  question  must  always  be  answered 
in  the  affirmative,  unless  the  patient  is  actually  moribund.  There  is  no  sur- 
geon of  large  experience  who  has  not  seen  desperate,  and  apparently  hopeless 
cases  occasionally  recover.  The  situation  may  be  regarded  in  this  way:  A 
vessel  is  wrecked  and  a  lot  of  poor  wretches  are  thrown  into  the  sea.  The  chance 
of  saving  them  seems  desperate  from  the  shore,  but  a  few  determined  men  put 
out,  and  each  of  them  manages  to  bring  in  one  or  two  alive.  The  men  ashore 
excuse  their  inactivity  and  their  refusal  to  go,  on  the  ground  that  they  saw 
clearly  they  could  not  save  all.  Under  circumstances  where  death  is  certain, 
every  life  saved  is  pure  gain,  and  if  but  one  in  twenty,  one  in  fifty,  if  you  will, 
can  be  rescued,  the  effort  to  accomplish  this  end  is  obligatory.  An  interest- 
ing case  illustrating  this  point  is  given  by  Van  Lennep  (Hahn.  Med.  Month., 

.Ian..   1895). 

A  child  of  twelve  was  sent  to  him  after  a  Ions;  illness,  with  supposed  tu- 
bercular peritonitis.  The  abdominal  distention  was  so  great,  and  the  child  so 
nearly  dead,  that  the  operation  was  begun  almost  without  anesthesia.  On  open- 
ing the  abdomen,  pus  poured  out  as  from  a  geyser,  and  it  was  estimated  that 
fully  two  gallons  of  it  were  evacuated.  The  abscess  was  bounded  by  the  floorof  the 
pelvis,  the  abdominal  walls,  the  spine,  and  the  diaphragm;  up  under  the  latter 
the  intestines  were  squeezed  into  an  inconceivably  small  space.  The  patient  made 
a  surprising,  though  tedious  recovery. 

McCosh  and  Hawkks  {Amer.  .Jour.  Med.  Sci.,  May,  1897)  give  an  analysis 
of  00  cases  of  appendicitis  treated  surgically  at  the  Presbyterian  Hospi- 
tal, New  York,  between  January,  1895,  and  1897,  the  results  of  which  are  of 
considerable  interest  in  this  connection.  The  patients,  generally  speaking, 
were  brought  to  the  hospital  in  a  desperate  condition.  "As  a  rule,"  the  writers 
remark,  "the  ambulance  was  summoned  ;is  a  last  resort,  after  medical  treat- 
ment had  been  employed  for  days  and  even  weeks ;  indeed,  several  of  the 
patients  were  sent  to  the  hospital  by  their  friends  simply  for  purposes  of  eu- 
thanasia." The  average  duration  of  the  acute  cases  was  nine  days,  the  shortest 
being  twenty-four  hours,  and  the  longest  seven  weeks.  In  spite  of  these  un- 
toward  conditions  the  statistics  were  as  follows: 

Out  of  ol  cases  operated  upon  before  the  development  of  general  peritonitis, 
there  were  50  recoveries  and  only  1  death.     Out  of  11  cases  in  which  septic 


DESPERATE   CASES.  509 

peritonitis  developed  prior  to  admission,  9  were  operated  upon  and  2  were  not; 
out  of  the  9  cases  operated  upon,  there  were  6  deaths  and  3  recoveries. 

The  writers  especially  call  attention  to  the  fact  that  during  the  second 
of  the  two  years  covered  by  their  report,  it  had  become  noticeable  that  pa- 
tients were  sent  to  the  hospital  at  an  earlier  stage  of  the  disease  than  formerly, 
and  they  express  the  hope  that  this  fact  signified  a  realization  of  the  impor- 
tance of  early  operation,  not  only  on  the  part  of  physicians,  but  by  the  general 
public.  It  is  evident  that  in  such  cases  as  these  the  patient  has  everything 
to  gain  by  operation  and  nothing  to  lose,  so  that  every  case  saved  is  clear  profit. 
The  only  contraindication  to  operation  is  the  certainty  of  approaching  death, 
expressed  by  a  small  weak  pulse,  anxious  expression,  dusky  skin,  and  a  com- 
posite of  signs  and  symptoms  quickly  read  by  the  experienced  surgeon,  but 
not  easily  described. 


CHAPTER  XXIII. 
PRELIMINARIES  TO  OPERATION. 

MEDICAL  TREATMENT.     PREPARATIONS  FOR   OPERATION.      NITROUS  OXID 
ANESTHESIA.     COCAINE  ANESTHESIA. 

MEDICAL  TREATMENT. 

Before  proceeding  to  consider  the  question  of  operation,  it  seems  suitable 
to  say  a  few  words  upon  the  medical  treatment  of  appendicitis;  that  is  to 
say,  to  consider  briefly  what  remedies  it  is  advisable  to  apply  in  any  ease 
until  the  services  of  a  surgeon  can  be  secured,  as  well  as  the  best  measures 
of  relief  in  cases  which  do  not   require  operation. 

The  first  step,  which  is  of  prime  importance  in  the  treatment,  is  t  o  put 
the  patient  to  bed,  and  keep  him  quiet  in  the  dorsal 
position:  the  next  is  a  r  i  g  0  r  o  u  s  r  e  g  ul  a  ti  0  a  0  f  diet,  m  e  d  i- 
cation,  and  treatment  in  general,  all  of  which  is  best  carried 
out  by  a  trained  nurse,  acting  under  careful  surveillance  from  hour  to  hour, 
until  all  danger  is  past.  If  the  patient  is  constantly  watched  by  a  nurse,  and 
the  surgeon  makes  his  visit,  at  first,  from  two  to  four  times  a  day.  any  increase 
in  the  symptoms  denoting  an  undue  extension  of  the  disease  will  at  once  he 
noted,  and  the  surgeon  will  he  in  readiness  to  abandon  the  medical  treatment 
without  a  moment's  delay,  in  order  to  attack  the  disease  by  the  more  direct 
measures  of  surgery. 

Of  equal,  if  not  greater  importance  to  general  rest  of  the  body  at  large, 
is  local  rest  of  the  alimentar  y  tract,  and  the  first  care,  after 
putting  the  patient  to  bed,  must  lie  the  absolute  withdrawal  of 
food;  a  step  taken  for  two  reasons,  first,  to  secure  that  freedom  from  peri- 
stalsis which  is  only  found  in  an  empty  intestinal  tract,  ami,  second,  to  unload 
the  bowel  of  such  materials  as  might  in  case  of  rupture  escape  into  the  peri- 
toneum. In  cases  where  the  stomach  contains  remnants  of  food,  A.  J.  OcHSNER 
{Appendicitis,  1902)  recommends  gastric  lavage,  by  first  spraying 
the  pharynx  with  a  \  per  cent,  solution  of  cocaine,  and  then  introducing  a 
Stomach-tube  and  irrigating  with  a  normal  salt  solution.  This  form  of  treat- 
ment is  also  endorsed  by  Jonnesco  (Rev.  de  chir.,  1903,  No.  6).  As  long  as  there 
is  vomiting  the  patient  has  but  little  desire  for  food,  and  thirst  may  lie  satisfied 
with  little  sip-  of  iced  water,  a  little  cold  tea  in  coffee-spoonful  measures,  or  hot 
water  to  rinse  the  mouth.  Sometimes  minute  quantities  of  champagne  are 
helpful. 

510 


MEDICAL   TREATMENT.  511 

Ice  should  be  applied  locally  over  the  right  iliac 
fossa  in  a  rubber  bag,  spread  out  thin  so  as  to  cover  a  wide  area,  and  not 
heavy  enough  to  produce  discomfort  by  its  weight.  The  bag  should  be  sep- 
arated from  the  skin  by  a  layer  of  flannel,  and  the  ice  often  renewed.  D.  H. 
Williams  uses  menthol  dissolved  in  alcohol  locally  for  the  relief  of  pain. 
Thin  poultices  sprinkled  with  tincture  of  opium  may  also  be  used  over  the 
entire  abdomen. 

The  treatment  of  the  bowels  constitutes  the  crux 
of  the  subject  to-day.  Some  surgeons  arc  still  loud  in  their  praises 
of  the  advantages  accruing  from  free  purgation,  especially  with  saline  cathar- 
tics. The  opinion  of  most,  however,  is  largely  in  favor  of  keeping  the  bowels 
entirely  at  rest  by  the  use  of  opium  or  morphine,  in  order  to  check  peristalsis. 
a  method  strongly  advocated  by  some  of  the  earliest  writers  on  appendicitis. 

The  first  mention  of  the  subject  is  by  two  English  physicians.  Graves  and 
Stokes  (Duhl.  Hosp.  Rep.,  1830),  who  advocated  the  treatment  of  intestinal 
perforation  and  resulting  peritonitis  by  means  of  opium  in  large  closes,  urging 
its  use  on  the  ground  that  it  favors  the  organization  of  protective  false  mem- 
brane, and  supports  the  vital  powers  at  a  time  when  they  are  at  their  lowest 
ebb.  They  state,  with  creditable  frankness,  that  the  antiphlogistic  treatment, 
then  universally  employed  in  such  cases,  had  resulted  fatally  in  all  of  the  seven 
which  they  report,  while  they  are  convinced  that  one  of  these,  which  was  im- 
proving under  opium,  might  have  been  saved,  had  not  the  treatment  been 
discontinued  in  favor  of  blood-letting  and  purgatives.  Two  years  later  one 
of  these  writers.  Stokes,  published  a  second  paper  on  the  same  subject,  in  which 
he  was  able  to  report  two  cases  of  recovery  under  the  treatment  recommended. 
In  1837,  a  Frenchman,  Petreqtjin,  again  brought  forward  the  opium  treat- 
ment with  special  reference  to  perforation  situated  in  the  vermiform  appendix 
and  the  resulting  peritonitis,  using  in  its  favor  the  arguments  of  Graves  and 
Stokes,  whom  he  quotes  (Gaz.  mnl.  de  Paris,  1837,  p.  368).  He  gives  in  detail 
one  case  of  appendicitis  in  which  the  diagnosis  was  made  and  the  treatment  with 
opium  begun  after  perforation  had  occurred.  The  opium  was  then  continued 
for  seven  days,  184  grains  being  given  in  that  time,  inducing  complete  narcosis. 
The  patient   made  an  excellent   recovery. 

Nearly  ten  years  later  a  German.  Adolph  Volz,  published  an  inaugural 
dissertation  (see  Chap.  II.  p.  18)  in  which  he  argues  most  earnestly  in  favor 
of  the  use  of  opium  in  perforation  of  the  appendix,  and  accompanies  his 
arguments  with  substantial  proofs  of  its  efficacy.  He  first  cite-  38  eases 
of  perforation  of  the  appendix  treated  with  blood-letting  and  purgatives,  all 
of  which  einled  fatally,  the  diagnosis  being  confirmed  in  every  case  by  the 
autopsy.  He  then  gives  14  cases  in  which  the  characteristic  symptoms  of 
appendicitis  were  present,  accompanied  by  peritonitis,  usually  circumscribed, 
but  sometimes  general.  All  of  these  recovered  under  the  administration  of  opium 
in  doses  of  one  grain  every  half-hour,  continued  until  the  pain  was  distinctly 


oil'  PRELIMINARIES   TO    OPERATION. 

relieved,  when  the  dose  was  gradually  reduced.  One  of  these  cases  died  seven 
months  later  of  tuberculosis  of  the  lungs,  and  an  autopsy  which  was  then  held 
showed  no  signs  of  tubercles  in  the  intestines.  |>ut  made  it  evident  thai  the 
appendix  had  at  some  time  been  the  seat  of  a  morbid  process,  for  there  was 
evidence  of  a  pus  pockel  at  its  blind  extremityand  a  aumber  of  strong  fibrous 
adhesions  were  present  which  could  only  have  resulted  from  a  peritonitis  of  a 
very  high  grade.  Volz  claim-  that  these  cases  should  he  sufficient  to  estab- 
lish the  opium  treatment,  and  he  expresses  a  hope  that  the  day  will  come  when 

the  principle  of  rest  for  the  intestines  in  inflammation  of  the  appendix  by  means 
of  opium  will  be  as  clearly  recognized  as  the  same  principle  for  a  broken  leg 
by  means  of  splints  (see  (.'hap.  II.  p.  20).  The  antiphlogistic  treatment  he 
characterizes  as  imprudent  and  irrational. 

Notwithstanding  this  convincing  evidence,  however,  and  the  able  reasoning 
which  accompanied  it,  the  opium  treatment  never  came  into  general  use  in  any 
country,  although  from  time  to  time  it  has  been  individually  advocated. 
In  the  report  of  one  of  the  early  meetings  of  the  Pathological  Society 
of  New  York  (Amer.  Med.  Month.,  1858,  vol.  in.  p.  359)  there  is  a  discus- 
sion in  which  it  seems  to  have  met  with  favor  in  several  quarters,  and 
Markoe,  in  particular,  described  a  case  in  which  he  had,  successfully  treated 
a  perforation  of  the  appendix  with  large  doses  of  opium,  and  the  death  of  the 
patient  within  a  year  from  other  causes  had  afforded  the  opportunity  for  an 
autopsy,  which  confirmed  the  previous  diagnosis,  and  showed  that  the  process 
of  repair  after  perforation  had  actually  taken  place  (see  Chap.  XIII.   p.  327). 

It  is  a  g 1  plan  to  begin  the  administration  of  opium  by  giving  the  patient 

just  enough  to  relieve  pain  and  afford  a  little  ease,  either  in  the  form  of  morphine 
hypodermically,  or  in  small  doses  of  opium  I  j  to  \  a  grain)  by  tic  mouth.  The 
principle  of  its  use  is  to  •'splint"  the  bowels,  ami  by  checking  peristalsis  to 
favor  the  formation  of  adhesions  which  wall  off  the  affected  area  and  prevent 
a  general  peritonitis.  It  should  lie  kept  up  for  several  days,  until  all  the 
symptoms  have  subsided,  and  a  general  improvement  is  noted.  The  form 
of  its  administration  may  be  varied  by  using  the  aqueous  extract  or  the  tinc- 
ture in  small  starch  enemata. 

After  complete  subsidence  of  the  symptoms  the  bowels  may  be  unloaded 
by  small  oil  enemata.  given  at  intervals  of  several  hours,  or  by  calomel  or  cas- 
tor oil  given  by  the  mouth.  The  use  of  strong  salines  for  the  purpose  of  empty- 
ing the  bowels  in  these  cases  has  SO  often  been  associated  with  disastrous  results 
that  it  is  probably  wiser  to  abandon  them  altogether.  A  large  enema 
is      also      extremely      dangerous:    cases     have     been     reported    in 

which  a  considerable  portion  <<\  one  has  been  subsequently  discovered  by 
the  surgeon  lying  among  the  intestines  in  the  abdominal  cavity.  The  sur- 
geon will  sometimes  find  it  of  advantage  to  introduce  a  well-oiled  finger  into 
the  rectum,  and  then,  if  he  finds  impacted   iccc<.  to  soften  them  and  empty 

the   bowel   by   throwing  in   a    few   ounces   of  sweet    oil. 

"When  using  opium,  it  must   be  constantly  borne  in  mind  that  large  doses 


PREPARATIONS   FOR   OPERATION'. 


513 


have  the  disadvantage  of  obscuring  the  clinical  picture,  and  concealing  the 
real  condition  of  the  patient.  It  relieves  the  pain  and  sensitiveness  only  in  an 
artificial  way,  and  the  nieteorism  which  it  causes  obscures  palpation.  Only 
enough  opium  should  b  e  g  i  v  e  n  to  produce  quiescence, 
the  pupils  being  watched,  and  the  urine  kept  under  observation  in  order  to 
be  sure  that  it  is  not  too  much  diminished  in  quantity;  the  sensorium  also 
must  not  be  too  much  obtunded.  With  improvement,  both  local  and  general, 
small  quantities  of  food  may  be  given  by  the  mouth,  beginning  with  albumen 
and  water,  a  little  cold  coffee,  or  tea.  Small  nutrient  enemata  may  be  given 
even  in  the  midst  of  the  attack,  and  continued  until  convalescence. 


PREPARATIONS  FOR  OPERATION. 
The  operative  treatment  of  appendicitis  is  daily  becoming  more  and  more 
frequent  as  its  results  appear  more  and  more  satisfactory.  In  order  to  ascertain 
what  proportion  operations  for  the  removal  of  the  appendix  bear  to  other 
surgical  operations  in  our  large  hospitals,  I  have  collected  statistics  on  the  sub- 
ject from  the  following  reports,  and  I  present  them  here  in  tabular  form.  It 
will  lie  seen  that,  although  there  is  considerable  variation  among  them,  the  pro- 
portion of  appendix  operations  to  others  is  large  in  every  case. 

RATIO  BETWEEN  OPERATIONS  ON  THE  APPENDIX  AND  GENERAL  SURGICAL 

OPERATIONS  IN  HOSPITALS 


Hospital 

Period  Covered 
by  Report 

Totai.  Number 

of 

Surgical  Operations 

Operations 

on 

Appendix 

Ratio 

Roosevelt     Hospi- 
tal, New  York. 

January    1,   1902, 
to  December  31, 

1002 

1319 

179 

1  in    7  + 

St.  Luke's  Hospi- 
tal, New  York. 

i  letober   1,    1901, 
to      September 
30,  1902 

1383 

167 

1  in    8  + 

University      of 
Pennsylvania 
Hospital,  Phila- 
delphia. 

Year   ending   De- 
cember 31,  1901 

972 

46 

1  in  21  + 

German    Hospital. 
Philadelphia. 

Year  1902 

1210 

437 

1  in    3  — 

llassachuset  t  s 
General    Hospi- 
tal, Boston. 

January   1,   1902, 
to  December  31, 
1902 

3266 

389 

1  in    8  + 

Boston  City  Hos- 
pital. 

February  1.  1902, 
to  Januarv  31, 
1903 

1928 

171 

1  in  11  + 

Mercy      Hospital, 
Chicago. 

October    1,    1900, 
to    October    1, 
1901 

741 

148 

1  in    5 

Johns     Hopkins 
Hospital,   Balti- 
more. 

February  1,  1900, 
to  Januarv  31, 
1901 

1697 

106 

1  in  Hi 

33 


,~>l  I  PRELIMIN  LRIES    TO    OPERATION. 

Preparation  of  the  Patient.  T  he  p  r  e  par  a  t  i  o  n  <>  f  t  h  e  p  a  t  i  e  n  t 
is  often  largely  in  the  hands  of  the  medical  man  who  has  first  seen  the  case, 
and  the  wise  physician  having  in  view  the  possible  necessity  of  an  incision  in 
the  abdominal  wall,  will  avoid  using  any  blistering  application,  such  as  canthari- 
des  or  iodine,  which  is  liable  to  be  followed  by  suppuration,  for  it  introduces 
a  grave  risk,  namely,  the  danger  of  infecting  the  abdominal  cavity.  Immediately 
preceding  operation,  while  the  active  preparations  are  under  way.  a  small  dose 
of  morphine,  1  or  ^ofagrain,  with  ,,',„  of  a  grain  of  atropine,  is  often  of  value 
in  quieting  the  nervous  system,  and  preparing  the  patient  to  look  forward  with 
equanimity  to  the  surgical  procedure.  11  the  bowels  are  loaded,  a  small  enema 
may  be  cautiously  given.     All   f 1  should  be  withheld. 

Cleansing  the  Field  of  Operation. — The  field  of  opera- 
tion should  be  cleansed  by  scrubbing  the  skin  well  with  warm  water  and  soap, 
applied  with  a  piece  of  gauze  over  the  entire  right  abdomen;  follow- 
ing this,  a  little  alcohol  or  ether  may  lie  used  to  remove  fat,  and  a  solution  of 
bichloride  1:  L000  to  further  sterilize.  The  most  important  feature  is  the  soap 
ami  water.  If  an  abscess  is  suspected,  great  care  must  lie  exercised  not  to 
rub  too  vigorously  for  fear  of  bursting  it.  If  there  is  a  suppurating  area,  fol- 
lowing a  blister  or  a  mustard  plaster,  in  the  line  of  the  incision,  it  is  best  to 
sterilize  it  with  a  strong  solution  of  permanganate  of  potash,  followed  by  one 
of  saturated  oxalic  acid,  each  of  them  being  applied  only  for  a  few  seconds,  and 
the  surface  then  scraped. 

Posture. — The  besl  posture  for  the  patient  is  the  dorsal  one,  with  the 
right  leg  slightly  flexed.  The  Trendelenburg  posture  is  a  disadvantage  here. 
Sometimes  it  is  of  material  assistance  in  exposing  the  cecum  and  appendix  to 
elevate  the  right  side  so  that  the  small  intestines  will  gravitate  toward  the 
left  and  out  of  the  way. 

Preparation  in  a  Private  House. — Operations  I'm'  appendicitis  musl  al- 
ways lie  done  with  frequency  in  private  houses,  owing  to  the  fact  that  in  a 
large  proportion  of  cases  by  the  time  the  surgeon  arrives  the  condition  of  the 
patient  is  such  as  to  demand  immediate  operation,  and  to  forbid  removal  to 
a  distant  hospital.  There  is  no  valid  reason  why,  with  due  precaution  and  a 
satisfactory  artificial  light  at  hand,  the  surgeon  should  not  do  as  good  work 
in  the  patient's  house  as  in  a  hospital.  In  an  interval  operation  the  incision 
is  small,  and  when  closed,  sealed,  and  covered  by  dressings  is  no  more  liable 
to  infection  than  a  similar  wound  in  a  hospital.  If  an  ahscess  has  to  lie  drained, 
it  can  he  done  equally  well  in  either  place.  Some  surgeons  even  find  the  statis- 
tics of  their  private  work  better  than  those  of  the  hospital.  In  a  private  house 
there  is,  moreover,  the  advantage  of  a  well-chosen  trained  nurse,  working  in 
a  spirit  of  fidelity  to  both  surgeon  and  patient,  a  thing  not  always  found  in  a 
hospital,  where  the  sense  of  personal  responsibility  on  the  part  of  the  atten- 
dants is  often  dulled.     The  disadvantages  of  a  private  house  are  that,  as  a  rule, 


PREPARATION    IN    A    PRIVATE    HOUSE.  515 

serious  complications  are  not  so  well  provided  for,  and  the  surgeon  loses  much 
more  time  in  visiting  his  patients. 

A  well-lighted  room  should  be  chosen  for  operation,  if  possible  near  the 
bath-room.  Abundance  of  hot  water  must  be  available,  and  if  there  is  sufficient 
time,  the  room  should  be  cleaned,  the  floor  scrubbed,  and  afterward  a  drugget 
laid  upon  it  and  sprinkled.  The  room  must  be  bared  of  all  unnecessary 
articles  of  furniture,  such  as  upholstered  chairs,  pictures,  and  mantel  orna- 
ments. A  single  bed  must  be  provided,  standing  at  a  height  of  26  to  28  inches, 
including  the  mattress;  an  ordinary  bed  can  lie  made  to  serve  the  purpose 
by  placing  it  on  blocks.  This  will  save  both  surgeons  and  attendants  much 
awkwardness  in  the  subsequent  care  of  the  wound  and  the  bowels,  as  well  as 
in  bathing  and  turning  the  patient.  Several  small  tables,  about  3X2  feet, 
should  be  brought  in  for  the  instruments  and  dressings,  and  a  bench  or  some 
chairs  provided  for  the  basins  of  water  and  solutions.  The  operating  table, 
which  should  be  a  portable  folding  table  like  that  of  Edebohls,  must  be  sent 
in  by  the  surgeon  himself.  A  gas  stove,  and  an  Arnold  or  a  Beckmann  steril- 
izer are  necessary  for  the  dressings,  towels,  and  sheets.  The  surgical  instru- 
ments should  be  sterilized  at  home,  and  packed  ready  to  use  on  taking  them 
out  of  the  kit. 

The  instruments  and  other  articles  needed  in  operating  at  a  private  house 
are:  Operating  table;  water  and  solution  basins;  scalpels;  dissecting  for- 
ceps (2);  artery  forceps  (12);  retractors;  ligature  and  suture  materials;  scis- 
sors; needles,  including  line  intestinal  needles;  needle-holders:  gauze  for 
packing,  and  sponges,  carefully  counted;  iodoform  gauze  strips  for  drainage; 
hypodermic  syringe;  chloroform,  ether,  nitrous  oxid  gas,  cocaine,  and  supra- 
renal extract;  apparatus  for  saline  infusion;  towels  (about  two  dozen);  culture- 
tube  and  platinum  loop;  a  bottle  of  formalin  (10  per  cent.),  or  of  alcohol,  for 
the  appendix. 

Only  a  few  of  these  instruments  require  any  special  description.  The 
most  convenient  retractors  are  those  with  blunt  teeth,  made 
in  a  curve.  The  needle-holder  is  the  Reiner,  with  the  beak 
made  small  in  order  to  hold  the  needles  without  breaking 
them.  For  intestinal  suturing  I  use  the  delicate,  round, 
Trench  needles  with  the  split  eye,  and  fine  black  silk  (see 
Fig.  230).    The  delicate  forceps  are  of   the   kind  which  I     „    „„    , 

°  '  r  Fig.  236. — Intestinal 

use  in  intestinal,  ureteral,  and  vesical  work  (see  Fig.  237).  Needm  with  split 

On  grasping  the  tissues  with  them,  but  slight  injury  is  done.  ^ 

and   at  the  same   time   they  are   adapted   to   catch  up  the  moniy  used  is   often 

tissue  at  any  point  and  hold  it  for  the  passage  of  the  finest  j"">C  the  '  JL  hire 

needles.     The  mosquito  forceps,  which  I  have  adopted  from  "cured, 
the  surgical  staff  of  the  Johns  Hopkins  Hospital,  are  con- 
venient for  grasping  small  vessels  in  delicate  tissues   in  the  peritoneum,  or 

about   the    base   of   the  appendix.     I    have   modified    them  for    the    purpose 


51(5 


PRELIMIN  \Kli;s    TO    OPERATION. 


Fig.  237. — Delicate  Light  Curved  Mouse-tooth  Forceps  v"h  Picking  dp  the  Bowel  and  Holding  it  while 

nik  Smuts  ahi    1'assi  i.      i  Vwn  •lui.i    natural  size.) 


of  grasping  and   retaining   tissues    by   adding    a 
teeth. 


broad 


point    and    several 


ANESTHESIA. 

It  is  unnecessary  to  devote  time  and  space  here  to  the  discussion  of  the 
familiar  anesthetics,  chloroform  and  ether.  Ether  is  to  be  preferred,  as  a  rule, 
on  account  of  its  greater  safety,  but  chloroform  is  the  better  of  the  two  for 

children  ami  for  old  people,  as  well  as  when  there  is  a  tendency  to  bronchitis, 
or  in   the  presence  of  nephritis. 

Nitrous  Oxid  Gas. — During  the  past  decade  sundry  efforts  have  been  made 
to  render  the  process  of  anesthetization  less  unpleasant  to  the  patient,  and  less 
tedious  to  the  operator.  The  one  method  which  has  proved  itself  satisfactory 
is  the  combined  nitrous  oxid  and  ether  method,  in  which  nitrous  oxid  gas  is 
used  to  induce  unconsciousness  and  followed  by  the  administration  of  ether. 
Chloroform  cannot  he  used  under  these  conditions,  as  it  is  dangerous  to  follow 
the  depressing  effects  of  the  partial  asphyxiation  of  nitrous  oxid  pis  by  such 

a  cardiac  depressant. 

The  rapidity  of  the  nitrous  oxid  method  is  of  advantage  to  the  patient, 
the  surgeon,  and  the  anesthetizer;  since  the  time  required  for  loss  of  conscious- 
ness with  the  gas  is  only  from  one.  to  two  and  a  half  minute-,  and  the  time 
necessary  to  secure  complete  anesthesia  from  one  to  five  minutes.  The 
patient  is  also  relieved  from  the  unpleasant  sensations  induced  by  the  admin- 
istration of  ether,  and  in  most  cases  suffers  much  less  from  disagreeable  after- 
effect-, especially  nausea  and  vomiting.  A  further  minor  benefit  is  the  smaller 
quantity  of  ether  required,  the  amount  necessary  to  maintain  unconsciousness 
after  anesthesia   has   been   induced   by   the  pis   having   been   estimated   at 


NITROUS   OXID   ANESTHESIA.  517 

50  to  70  grams  in  an  operation  lasting  twenty  minutes,  up  to  300  grams  in  one 
lasting  three  hours  and  forty  minutes. 

The  only  difficulties  in  the  use  of  the  method  are  an  occasional  cyanosis 
during  the  administration  of  the  gas,  and  an  increased  secretion  of  mucus.  A 
slight  degree  of  cyanosis  is  inevitable  in  most  cases,  but  if  the  anesthetize!-  is 
experienced  and  skilful,  any  marked  symptoms  of  asphyxia  are  present  in  but 
a  small  number  of  instances.  An  increased  secretion  of  mucus  is  rare,  and  is 
alwavs  much  less  than  after  the  administration  of  ether  alone.  The  nausea 
also  is  undoubtedly  less,  and,  as  a  rule,  is  absent  altogether.  Too  much  stress 
cannot  be  laid  upon  the  fact  that  in  the  use  of  nitrous  oxid  gas  the  anesthetizer 
should  be  thoroughly  familiar  with  the  method,  as  upon  this  its  success  largely 
depends;  most  of  the  instances  of  failure  or  of  unpleasant  results  having  been 
due  to  lack  of  experience,  or  to  want  of  skill.  It  is  occasionally,  but  rarely, 
impossible  to  secure  complete  anesthesia  with  nitrous  oxid  gas,  owing  either  to 
extreme  nervousness  on  the  part  of  the  patient  or  to  his  being  habituated  to 
the  use  of  stimulants. 

I  first  used  this  method  in  my  private  hospital  in  1900,  and  I  have  since 
found  it  most  satisfactory  in  many  hundreds  'if  anesthesias.  A  brief  account 
of  the  results  attending  its  use  during  the  first  eight  months  of  my  experience 
has  been  published  by  my  associate.  T.  R.  Brown  ("Oh  new  methods  of  anes- 
thesia.- Phila.  Med.  Jour.,  Nov.  3,  1000). 

Nitrous  oxid  gas  has  also  been  employed  with  good  results  as  the  sole 
anesthetic  in  prolonged  operations,  such  as  those  for  removal  of  the  appen- 
dix, where  disease  of  the  kidneys  renders  anesthesia  by  ether  or  chloro- 
form dangerous  to  life.  I  have  tried  it  in  several  cases  of  appendicitis 
when  other  anesthetics  were  contraindicated  for  this  reason,  with  excellent 
results.     Let  me  cite  one  such  case  in  illustration. 

Mrs.  A.  (San.  No.,  1324.",,  March.  1902.)  Operation  for  chronic  appendicitis. 
Nitrous  oxid  gas  was  chosen  as  an  anesthetic  because  of  chronic  nephritis  and  a  persis- 
tent albuminuria  of  thirteen  years'  standing,  without  casts.  The  patient  was  under 
the  anesthetic  for  one  hour  and  six  minutes,  during  all  of  which  time  she  was  com- 
pletely unconscious.  Her  pulse  before  anesthesia  was  100.  and  afterward  SO.  There 
was  no  nausea  after  the  operation,  and  although  a  little  was  complained  of  at  the  end 
of  twenty-four  hours,  it  was  very  slight,  and  she  .suffered  less  than  the  usual  amount 
of  pain.  She  made  an  uninterrupted  recovery,  the  only  point  presenting  anything 
unusual  being  that  she  slept  almost  continuously  for  the  first  week.  The  secretion 
of  urine  was  not  diminished. 

My  experience  in  this  and  other  cases  has  convinced  me  that  nitrous 
oxid  gas  can  be  employed  as  the  only  anesthetic  during  long  operations  with 
perfect  safety,  and  I  strongly  recommend  its  Use  when  the  existing  conditions 
contraindicate  the  use  of  ether  or  chloroform. 

Cocaine.— It  frequently  happens  that  an  operation  for  appendicitis  is  advis- 


518  PRELIMINARIES   TO    OPERATION. 

able  or  necessary  when  the  administration  of  any  general  anesthetic  is  contraindi- 
cated  by  the  existence  of  morbid  processes,  such,  for  instance,  as  chronic  pulmon- 
ary or  cardiac  lesions.  Under  these  circumstances  the  use  of  a  local  anesthetic, 
such  as  cocaine,  becomes  most  valuable.     An  illustrative  case  is  here  given: 

A  young  man,  twenty-one  years  old,  developed  a  primary  tuberculosis  of  the 
larynx  at  the  cud  of  his  college  career.  The  opportunity  was  offered  him  of  recruit- 
ing in  a  remote  camp  in  the  Carolina  mountains.  Under  the  advice  of  a  specialist  he 
was  desirous  of  taking  advantage  of  this  opportunity,  but  as  he  had  had  several 
attacks  (if  appendicitis  during  the  preceding  year,  the  last  of  considerable  severity, 
he  was  afraid  of  being  removed  from  the  possibility  of  surgical  aid  fur  such  a  length 
of  time.  As  the  removal  of  the  appendix  seemed  justified  by  the  circumstances, 
and  as  the  condition  of  his  larynx  contraindicated  the  inhalation  of  either  ether 
or  chloroform,  the  appendix,  which  proved  to  be  adherent,  strictured,  and  filled  by 
a  concretion,  was  removed  under  local  cocaine  anesthesia.  In  ten  days  he  was 
able  to  leave  the  hospital  for  his  proposed  outing. 

The  operation  on  this  particular  patient  was  performed  in  the  spring  of 
1899,  by  Harvey  Cushing,  and,  so  far  as  I  am  aware,  il  was  the  first  in  which 
the  appendix  was  removed  under  local  anesthesia. 

Diseases  of  the  blood-vessels,  of  the  m  y  0  C  a  r  d  i  u  in  ,  or 
of  the  res  p  i  r  a  t  o  r  y  tract,  a  in  a  r  k  e  d  a  n  e  m  i  a  ,  a  suspect  e  d 
r  e  n  a  1  ins  u  f  f  i  c  i  e  n  c  y,  an  i  n  f  e  C  1  i  0  us  d  i  s  e  a  s  e,  either  in  itself 
the  cause  of  the  local  process,  or  merely  a  concomitant  illness,  ami  many  other 
conditions  as  well,  might  lie  cited  as  involving  considerable  risk  in  administer- 
ing the  usual  anesthetic.  The  dangers  arising  from  them  apply,  of  course, 
not  only  to  the  operation  for  removal  of  the  appendix,  but  to  any  operative 
procedures  called  for  during  their  progress.  During  typhoid  fever,  for  example, 
it  is  well  known  thai  the  administration  of  ether  or  chloroform  may  have  most 
serious  consequences,  and  only  since  the  introduction  and  general  use  of  local 
anesthesia  in  these  cases,  has  the  high  mortality  rate  following  operations  for 
perforation  and  for  cholecystitis,  as  well  as  for  an  associated  appendicitis,  been 
considerably  lowered.  On  several  occasions,  cases  of  suspected  typhoid  per- 
foration, from  the  clinic  of  my  colleague,  AY.  Osler,  have  been  explored  under 
a  local  anesthesia,  and  an  acutely  inflamed  .appendix  found  to  have  occasioned 
the  symptoms.  The  removal  of  the  appendix  in  these  cases  was  not  followed 
by  any  fatalities. 

There  are  three  different  methods  of  using  a  local  anesthetic  for  operative 
purposes,  but  only  one  of  them  is  widely  applicable  to  the  operation  in  question : 

I.  Segmental  anesthesia,  produced  by  lumbar  subarachnoid 
injection  of  the  drug,  which  thus  acts  symmetrically  on  the  posterior  nerve 
roots   of   the   two  sides   up   to  a   variable  segmental   level. 

II.  1'  e  g  i  o  n  a  1  a  n  e  s  t  h  e  s  i  a  ,  in  which  a  certain  territory  is  ren- 
dered anesthetic  by  injection  of  a  solution  of  the  drug  directly  into    the    per- 


COCAINE    ANESTHESIA.  519 

ipheral  sensory  nerve  trunks,  at  a  distance  more  or  less  remote  from  the  opera- 
tive field. 

III.  Local  anesthesia  proper,  in  which  the  tissues  are  infil- 
trated and  divided  as  encountered  in  the  incision. 

The  first  two  of  these  methods  depend  for  their  efficacy  upon  the  physio- 
logic principle  of  "blocking''  sensory  impulses,  which  is  a  consequence  of  the 
local  action  of  the  drug. 

S  e  g  m  e  n  t  a  1  anesthesi  a  has  unfortunately  many  drawbacks.  In 
the  first  place,  it  is  necessary  that  a  solution  of  sufficient  concentration,  namely, 
1  to  2  per  cent.,  be  introduced  into  the  subarachnoid  space,  and  toxic 
symptoms  are  almost  invariably  seen  after  this,  with  fall  of  blood-pressure 
and  serious  symptoms  of  shock.  The  reasons  which  contraindicate  a  general 
anesthetic  in  critical  cases  prohibit  spinal  anesthetization  as  well.  Although 
it  may  not  Lie  injudicious  to  employ  this  method  in  selected  instances, 
there  has  been  a  very  natural  reaction  against  the  indiscriminate  use  of  Ben's 
procedure  in  the  generality  of  cases. 

Regional  anesthesia,  so  satisfactory  in  certain  operations,  such 
as  herniotomy,  or  operations  on  the  neck  or  extremities,  is,  unfortunately, 
hardly  applicable  to  removal  of  the  appendix,  when  the  operative  incision 
lies  in  a  territory  overlapped  by  the  lateral  and  anterior  cutaneous 
branches  of  two  or  three  of  the  lower  dorsal  nerves,  each  one  of  which 
would  consequently  have  to  be  separately  anesthetized  under  the  borders  of 
their  respective  ribs  before  an  analgesic  cutaneous  field  could  be  assured. 

Operations  for  removal  of  the  appendix  are,  therefore,  restricted  to  the 
infiltration  method,  or  local  anesthesia  proper,  and  the 
principles  of  technic  belonging  to  it  will  be  briefly  discussed. 

.Major  operations  under  local  anesthesia  are,  generally  speaking, 
considerably  more  difficult  than  those  performed  in  the  usual  manner.  In  the 
first  place,  it  is  distracting  to  the  operator  to  have  a  conscious  patient,  and 
exhausting  to  be  called  upon,  during  a  procedure  which  is  necessarily  more 
prolonged  than  would  otherwise  be  the  case,  not  only  to  operate,  but  to  as- 
sume the  responsibilities  of  sustaining  the  patient's  morale.  This  latter  duty 
should  partially  devolve  upon  an  assistant,  especially  detailed  to  play  the  part 
of  a  "moral  anesthetist,"  who,  by  occupying  the  patient's  attention,  by  encour- 
agement, and  by  attention  to  his  occasional  wants,  can  do  much  to  relieve  the 
surgeon,  although  the  successful  accomplishment  of  the  operation,  especially 
in  a  nervous  patient,  depends  largely  upon  the  moral  influence  of  the  operator 
himself.  It  is  needless  to  say  that  the  sight  of  the  operating;  room,  the  noise 
of  instruments,  or  anything  else  which  might  shock  the  sensibilities  of  the 
patient  is  to  be  studiously  avoided. 

The  method  of  operating  must  necessarily  be  quite  different  from  that 
commonly  followed.  Painstaking  and  tedious  dissection,  with  absolute  hemo- 
stasis  must  of  course  be  observed,  since  the  tissues  must  be  kept  dry  ami  free 


520  PRELIMINARIES   TO    OPERATION. 

from  blood-staining,  in  order  that  aerves  and  blood-vessels  unexpectedly  en- 
countered need  nut  be  divided  and  clamped  in  a  bloody  angle  of  the  incision. 
The  tissues  must  be  bandied  with  the  greatesl  circumspection  and  the  usual 
rough  methods  of  retraction  and  of  sponging  are  prohibited.  Familiarity 
with  the  neural  anatomy  of  the  region  is  essential,  a  subject  to  which  far  too 
little  attention  is  paid  in  ordinary  methods  of  operating.  The  accidental 
division  or  clamping  of  a  single  uncocainized  nerve  trunk,  unexpectedly  met 
with  in  the  parietal  incision,  may  promptly  and  completely  exhaust  whatever 
inhibition  the  patient  possesses  long  before  the  peritoneal  cavity  has  been 
opened.  Nerve  trunks  of  any  size  must  be  separately  anesthetized,  as  the 
infiltration  hardly  suffices  to  benumb  them,  and  difficulties  are  apt  to  arise 
because  vessels  and  nerves  are  likely  to  accompany  one  another.  Moreover, 
blood-vessels  of  any  size  are,  in  themselves,  apt  to  give  pain  when  crushed  with 
forceps. 

A  minimal  solution  of  cocaine,  or  one  of  its  equivalents, 
should  be  used.  V.  u  c  a  i  n  e  B,  for  example,  is  highly  recommended  by  many 
persons  as  being  less  toxic,  and  more  resistant  to  sterilization.  As  a  matter 
of  fact,  however,  such  weak  solutions  are  required  for  infiltration  purposes 
that  toxic  effects  should  never  be  seen,  ami  the  drug  withstands  high  tem- 
peratures sufficiently  well  to  waive  the  latter  objection.  The  solutions  most 
commonly  employed  are  those  advocated  by  Schleich  (Schmerzhse  Opera- 
tionen.  Vierte  Auflage,  Berlin,  1899),  in  which  the  cocaine  is  combined  with 
small  percentages  of  morphine  and  sodium  chloride.  Three  such  combinations 
are  given  by  him,  varying  only  in  the  percentage  of  cocaine,  his  No.  _  being  as 
applicable  to  the  general  run  of  cases  as  any  other  preparation:  Cocaine  liiur., 
0.1;   Morph.  mur.,  0.02;    Xatr.  chlor.,  0.2;   Aq.  destil.  ad  100.0. 

Weaker  solutions  than  this  1  :  1000  formula  may  be  satisfactorily  employed, 
even  up  to  a  0.01  per  cent,  solution;  as  a  matter  of  fact,  an  isotonic  saline 
solution,  when  infiltrated  so  as  to  produce  a  local  edema,  has  a  decidedly 
deadening  influence  upon  pain  transmission. 

It  has  recently  been  recommended  to  add  a  small  amount  of  adrenalin  to 
the  cocaine  solution  (a  few  drops  to  a  1  :  1000  solution  I  in  older  to  check  local 
venous  oozing,  which  is  sometimes  very  troublesome. 

Necessarily  there  is  always  a  certain  amount  of  pain  inflicted  in  operat- 
ing under  local  anesthesia,  although  this  becomes  relatively  insignificant  under 
the  management  of  those  experienced  in  its  use.  Ordinarily  no  adjuvant  to 
the  drug  is  called  for  beyond  the  influence  of  moral  suggestion,  already  empha- 
sized. Should  such  aids  be  indicated,  however,  it  is  well,  before  the  opera- 
tion, to  administer  hypodermically  a  small  dose  of  morphia  (J-  grain)  and  to 
hold  a  chloroform  mask  in  readiness  to  tide  the  patient  over  a  difficult  moment 
in  the  operation,  such  as  may  be  produced  by  the  introduction  of  gauze  for  pur- 
poses of  "  walling  off,"  or  by  the  manipulations  required  to  free  a  tightly  adherent 
appendix.     It  is  astonishing  how  few  whiffs  of  chloroform,  not  even  enough 


COCAINE   ANESTHESIA.  521 

for  a  "primary  anesthesia,"  will  suffice  to  accomplish  this  purpose,  and  indeed 
a  few  inhalations  of  spirits  of  ammonia  dropped  on  the  mask  may  be  no  less 
efficacious.  The  performance  lias  in  consequence  been  often  referred  to  as  the 
combined  "morphine-cocaine-chloroform''  method  of  anesthesia. 

There  are  certain  steps  in  the  operative  procedure  itself  where  especial 
precautions  must  be  taken.  To  make  the  skin  incision,  in  the  first  place,  is  a 
simple  matter,  provided  there  has  been  a  linear  wheal  of  local  edema  produced 
by  the  infiltration.  There  should  be  no  unpleasant  subjective  sensation  expe- 
rienced after  the  first  single  insertion  of  the  needle,  which  should  be  made  to 
follow  the  spreading  edema  in  the  line  of  proposed  incision.  An  ordinary 
hypodermic  syringe  or  two  will  suffice  for  the  injection,  although  many  per- 
sons prefer  a  syringe  with  a  larger  barrel,  as  it  obviates  the  necessity  for  exchang- 
ing or  refilling  the  smaller  instrument.  The  skin  incision  may  be  made  im- 
mediately after  the  completion  of  the  subcuticular  infiltration;  the  anes- 
thesia endures  long  enough  to  insure  the  possibility  of  a  painless  closure  at 
the  end  of  the  operation,  provided  a  subcuticular  running  suture  is  used 
insteail  of  the  through-and-through  suture,  which  would  penetrate  normal 
skin   outside  of  the  edematized   strip,   and   so  be   painful. 

The  most  difficult  part  of  the  operation  is  the  parietal  incision  through 
panniculus,  muscle,  and  serosa.  Care  is  necessary  in  going  through  the  fat, 
since  stray  filaments  of  the  cutaneous  nerves  may  lie  met  with,  and,  owing 
to  the  impracticability  of  edematizing  the  tissue,  such  fibres  must  be  in- 
dividually dealt  with.  The  aponeurosis  and  muscle  belly  of  the  external  ob- 
lique can  usually  be  opened  painlessly  in  the  direction  of  the  muscle  bundles, 
because  the  chief  nerve  trunks  lie  at  a  lower  level,  namely,  between  the  trans- 
versalis  and  internal  oblique  muscles.  The  incision  of  election,  furthermore, 
lies  more  or  less  parallel  with  the  direction  of  these  main,  buried  trunks,  and, 
as  a  rule,  midway  between  the  twelfth  thoracic  and  first  lumbar  nerves,  so  that 
the  incision  may  be  carried  directly  down  to  the  serosa  without  exposing  them. 
Whenever  the  incision  is  longer,  or  more  vertical  than  usual,  the  operator  should 
watch  for  these  nerves,  and  should  the  McBurney  incision  be  used,  and 
the  fibres  of  the  internal  oblique  be  separated  in  a  line  perpendicular  to  the 
more  superficial  opening,  both  nerves  will  almost  invariably  be  encountered. 
The  necessity  for  a  clean  and  bloodless  field  can  thus  be  appreciated.  Should 
the  division  of  these  nerves  be  deemed  essential,  one  or  two  drops  of  a  1 
per  cent,  solution  of  cocaine  may  be  injected  into  the  trunk,  as  far  dorsally  as 
possible;  the  peripheral  portion,  thus  rendered  anesthetic,  is  then  divided 
where  necessary. 

The  parietal  layer  of  the  peritoneum,  curiously  enough,  contains  sensory 
fibres,  and  may  need  cocainization,  although  a  simple  incision  through  it.  pro- 
vided it  is  uninflamed,  does  not  usually  give  much  discomfort.  Dragging  or 
pulling  of  the  peritoneum,  however,  with  retractors  or  with  gauze  is  painful, 
and   must   be  avoided  as  much  as  possible. 


522  PRELIMINARIES   To   OPERATION. 

The  abdomen  being  opened,  tli«'  viscera  may  be  handled  at  will.  Obser- 
vations under  local  anesthesia  mi  the  peritoneal  surface  have  shown  that  the 
visceral  serosa  is  completely  devoid  'if  sensory  nerves  of  any  sort.  Lennander 
has  especially  called  attention  to  this  point  in  his  "  Beobachtungen  uber 
die  Senstbilitdl  in  der  Bauchhohle"  (Mitth.  «.  <i.  Grensg.  <l.  Med.  u.  elm-.,  1902). 

The  appendix,  for  example,  may  lie  crushed,  ligated,  or  amputated  with- 
out the  patient's  being  aware  of  the  slightest  sensation.  The  same  may  he  said 
of  any  portion  of  the  gastro-intestinal  tract,  and  resections  and  anastomoses 
are  common  enough  under  local  anesthesia.  One  reservation,  however,  must 
he  made,  namely,  that  any  manipulation  which  causes  sullicient  tension 
upon  the  mesenteric  attachment  of  the  viscera  will  produce  pain  on  account 
of  the  stretching  of  the  adjoining  parietal  serosa.  This  pain  is  ordinarily 
of  a  reflex,  sickening  character,  and  is  referred  to  the  area  of  distribution 
of  the  corresponding  spinal  segments.  Thus,  in  my  experience,  tension  on 
the  mesappendix  occasioned  by  lifting  the  organ  into  the  wound  previous 
to  amputation  may  cause  the  characteristic  epigastric  pain  of  appendical 
colic  (see  Head's  Referred  Pain  of  Visceral  Disease).  In  consequence  of  this, 
should  the  appendix  in  an  interval  operation  be  tightly  adherent  to  the  parietal 
serosa,  or  should  the  latter,  in  an  acute  case,  be  inflamed  and  hypersensi- 
tive, a  few  whiffs  of  chloroform  may  be  necessary  before  liberation  of  the 
organ  can   he  satisfactorily  effected. 

Closure  of  the  wound,  as  a  rule,  offers  no  difficulties,  provided  the  skin 
edges  are  approximated  by  a  subcuticular  suture  not  passing  beyond  the  area 
of  original  edematization,  which  remains  insensitive  for  an  hour  or  two. 


CHAPTER  XXIV. 
INCISIONS. 

It  may  be  laid  down  as  a  general  rule  that  the  appendix  can  be  reached  in 
all  cases  where  a  liberal  incision  is  made  anywhere  in  the  right  lower  quad- 
rant of  the  abdomen;  that  is  to  say,  in  the  space  included  within  the  triangle 
indicated  by  a  line  drawn  (a)  from  the  umbilicus  to  the  symphysis,  (6)  from 
the  symphysis  along  Poupart's  ligament  to  the  anterior  superior  iliac  spine, 
(c)  from  the  umbilicus  around  to  a  point  on  the  crest  of  the  ilium  mid- 
way between  the  anterior  and  posterior  superior  spines  (see  Fig.  238,  p.  525). 
Xo  one  form  of  incision  is  best  in  all  cases,  for  its  location  must  lie  adapted  to 
the  condition  of  the  abdominal  wall  ami  to  the  stage  and  peculiarities  of  the 
disease.  If  the  abdominal  wall  is  rigid  and  thick,  it  is  easier  to  reach  the  ap- 
pendix when  the  incision  is  made  directly  over  it ;  if  the  wall  is  lax,  however, 
an  incision  made  anywhere  in  the  lower  quadrant  of  the  abdomen,  or 
even  in  the  median  line,  can  be  retracted  so  as  to  bring  the  appendix 
into  the  opening.  Whenever  the  local  signs,  such  as  swelling,  tenderness,  red- 
ness, and  edema,  are  pronounced,  they  should  determine  the  site  of  the  inci- 
sion. In  cases  in  which  swelling  is  pronounced,  the  incision  should  be  over 
its  most  prominent  part,  rather  to  the  outside,  especially  if  there  is  a  sausage- 
shaped  mass  or  plastron.  When  there  is  no  swelling,  but  localized  tenderness 
in  the  right  iliac  fossa,  the  incision  should  be  made  at  some  point  between 
the  right  rectus  muscle  and  Poupart's  ligament.  If  the  pains  persistently  follow 
one  particular  direction,  as  upward  toward  the  liver,  or  backward  toward  the 
kidney,  the  operator  will  do  well  to  bear  this  in  mind,  and  make  his  incision 
as  much  as  possible  over  the  course  of  pain,  since  the  appendix  will  probably 
lie  found  in  this  situation.  If  the  pain  is  situated  in  the  back,  the  appendix 
may  lie  behind  the  cecum,  or  to  its  outer  side,  and  it  is  best  to  make  the  incision 
posteriorly,  and  work  up  behind  the  cecum.  The  location  of  the  important 
nerve  trunks  encountered  in  making  the  various  incisions  is  shown  in  Fig. 
239  (p.  527). 

The  conditions  necessitating  operation  must  also  influence  the  choice  of 
incision.  From  this  standpoint  operations  for  removal  of  the  appendix  may 
be  classified   under  three  heads: 

1.  The  exposure  and  removal  of  the  appendix  for  disease  confined  to  the 
organ  itself.  In  this  case  the  incision  is  usually  made  at  some  point  over  or 
near  the  right  iliac  fossa. 

523 


.">_>  1  INCISIONS. 

2.  The  incidental  examination  and  removal  of  the  appendix  during  an  opera- 
tion undertaken  for  morbid  conditions  elsewhere,  such  as  gall-stones,  floating 
kidney,  inguinal  hernia,  or  disease  of  the  pelvic  organs.  The  question  then 
is  how  to  utilize  an  incision  made  for  another  purpose,  in  order  to  remove  the 
appendix  at   the  same  time. 

15.  The  removal  of  the  appendix  during  operations  rendered  necessary  by 

disease  of  another  organ,  which  disease,  there  is  reason  to  SUSpect,  is  secondary 

to  inflammation  of  the  appendix.     In  such  cases  the  complication  may  be  situ- 
ated at  some  distance  from  the  appendix,  and  the  choice  of  incision  must  then 

be  governed  by  the  necessity  of  relieving  both  conditions,  if  possible. 

A  number  of  different  incisions  have  been  employed  by  surgeons  of  ability 
and  experience,  ami  I  think  it  well  to  give  here  a  brief  description  of  some  of 
these  with  a  few  words  on  the  special  held  of  usefulness  in  each  case. 

Median  Incision. — (See  Fig.  240,  a  a.)  This  was  the  form  of  incision 
employed  in  all  the  earliest  celiotomies  for  removal  of  the  appendix.  So  soon, 
however,  as  the  operation  promised  to  become  at  all  general,  the  utility  of  an 
incision  in  the  median  line  began  to  he  questioned,  and  as  early  as  1888  there 
was  a  general  consensus  of  opinion  in  favor  of  abandoning  it  for  some  form 
of  lateral  incision,  either  vertical  or  oblique  [Trans.  Amer.  Surg.  Assoc.,  lsss, 
vol.  (i,  p.  IK!).  The  advantages  of  the  median  incision  are  that  no  nerves  or 
important  blood-vessels  are  encountered,  and  the  closure  of  the  wound  is  easily 
effected;  it  also  permits,  in  women,  an  easy  inspection  of,  and  operation  upon, 
all  the  pelvic  viscera.  Its  disadvantage  is  its  distance  from  the  iliac  fossa, 
which  often  necessitates  undue  traction  to  bring  the  appendix  into  view,  a 
serious  drawback  when  the  appendix  is  adherent  or  the  mesocolon  short.  In 
cases  where  the  abdominal  walls  have  been  stretched  by  a  pelvic  tumor  or  by 
repeated  pregnancies,  the  right  side  of  the  incision  is  easily  drawn  over  and 
the  right  iliac  fossa  fully  exposed,  hut  when  the  abdominal  walls  are  rigid  ami 
thick,  as  in  a  nullipara  or  in  a  man,  the  median  incision  offers  a  bail  route.  It 
is  never  now  deliberately  used  for  the  purpose  in  an  uncomplicated  appen- 
dicitis. It  may,  however,  be  employed  with  advantage  for  the  inspection  and 
removal  of  the  appendix  in  all  cases  where  chronic  appendicitis  complicates 
some  graver  affection,  as,  for  example,  an  ovarian  tumor,  a  fibroid  uterus,  or 
tubal  and  ovarian  disease  on  the  right  side.  The  peculiarity  of  the  median 
incision  when  used  under  these  conditions  is  that  it  must  be  a  long  one,  and 
should,  as  a  rule,  extend  not  less  than  two-thirds  or  three-fourths  of  the  way 
up  to  the  umbilicus,  in  order  to  allow  the  right  border  of  the  incision  to  be 
drawn  sufficiently  far  over  to  the  right  iliac  fossa  to  bring  the  appendix  within 
easy   reach. 

Vertical  Incision. — Incision  5  to  8  cm.  in  length,  along  the  outer  bor- 
der of  the  right  rectus  muscle.  The  advantages  of  this  incision  are  that,  as  the 
deep  tissues  are  purely  tendinous,  the  hemorrhage  is  slight,  ami  the  closure 
of  the  wound  easy  and  satisfactory.      Its  disadvantages  are  that  often  it  is  not 


Ext. obi. 


-Int.ohl. 


Fig.  238.     Showing  the  Mrscn.AR   iwn  Tendinous  Structures  Involved  in  Making  the  Various  Inci- 

BH  »NS. 

On  the  richt  side  the  panniculus  is  removed,  exposing  the  intaci  superficial  muscle,  the  external  obUque( 
and  the  rectus  in  its  sheath.  On  the  left  the  various  muscular  structures  are  seen  in  their  mutual  relations  in 
several  layers. 


1 1  ;$ 

•i,  m 


Ant    s 


\ 


'  I    i 


A .  circumfl .  :l  p>'rf-'' 


t-e'mor.w 


.LA*V. 


Fir..  239. — Representing  the  Principal  Arterial  and  Nerve-trunks  of  the  Right  Abdominal  Wall. 
The  larger  trunks  running  obliquely,  in  the  direction  of  the  ribs  extended,  are  found  between  the  internal 
oblique  and  transversalis  muscles.  The  smaller  branches  given  off  by  these  pass  out  toward  the  skin  or  deeper 
into  the  transversalis.  The  deep  epigastric  and  the  deep  circumflex  iliac  arteries  pass  in  under  the  surface  of 
the  abdominal  wall.  The  arrows  at  a  and  b  indicate  the  position  of  McRurney's  and  Battle's  incisions  respec- 
tively. It  is  of  great  importance  to  avoid  dividing  any  of  these  major  nerve  trunks  in  making  the  incision;  this 
is  best  effected  by  blunt  dissection. 


POSITION    OF    VARIOUS    INCISIONS. 


529 


directly  over  the  site  of  the  appendix,  and  therefore  the  operator  in  many 
cases  works  awkwardly.  Moreover,  drainage  is  sometimes  difficult.  The  ver- 
tical incision  was  that  employed  by  Morton,  by  Sands,  and  by  other  of  the 
earliest  operators  in  this  country.     It  was  introduced  into  Germany  by  .Schuller 


-v-: 


Fig.  240.— Cadaver  Showing  the  Location  of  the  Various  Incisions,  for  the  Removal  of  the  Appendix 
in  the  Right  Lower  Quadrant  of  the  Abdomen. 

The  body  wall  is  represented  as  Bemitransparent  in  order  to  show  the  position  of  the  underlying  viscera, 
a.  Median  incision;  b.  Battle's  incision;  c,  Lennander  and  Schuller  (vertical  incision);  d,  Morris;  e.  Fowler's 
oblique  incision  with  extensions;  f.  McBurney;  g,  Sonnenburg,  solid  line — skin  incision,  dotted  line — deep  in- 
cision along  Poupart'a  ligament;   h,  Fdebohls'  incision  for  both  kidney  and  appendix. 


(Arch.  f.  klin.  Chir.,  Berlin.  1889,  p.  845),  and  is  called  by  Krooius  "Schuller 's 

incision.     (See  Fig.  240.   b  b.) 

Sonnenburg.     (See    Fig.    240.    g  g.)     (Perityphlitis,    1900.   p.  324.)      The 

incision  is  made  close  to  the  ileum,  down  to  Poupart's  ligament.     It  is  seldom 

necessary  to  divide  the  epigastric  artery.     The  layers  divided  are:    The  skin, 
34 


530 


INCISIONS. 


Ant.  sup 


Fin.   241.—  McBurnev's  Incision  (I)   in  the  .Skin.      (See   p.   533.) 


FOWLKR  S    INCISION. 


531 


the  superficial  fascia,  the  external  oblique  muscle,  the  internal  oblique  muscle, 
the  transverse  muscle,  the  transverse  fascia,  and.  finally,  the  peritoneum. 
A  branch  of  the  circumflex  artery  must  usually  be  tied  off,  and  also  a  large 
vein  which  runs  outward  in  the  direction  of  the  incision. 

G.  R.  Fowler. — (Oblique   Incision,  Treatise  on  Appendicitis,  1894.  p.  156.) 


Fig.  242. — McBi'hnkv's  Incision  (II). 

Skin  retracted,  exposing  the  external  oblique  muscle  ami  its  aponeurosis;  the  muscular  fibres  are  only  found 
in  the  upper  half  of  the  exposed  area.  The  division  is  made  in  the  line  indicated  by  the  separatum  of  the  fibres 
in  the  figure.     (See  p.  533.) 


(See  Fig.  240,  e  e,  p.  529.)  Incision  two  to  three  inches  long,  the  middle  of 
which  intersects  at  right  angles  an  imaginary  line  drawn  from  the  right,  anterior, 
superior  iliac  spine  to  the  umbilicus.  The  direction  of  the  incision,  therefore, 
is  not  quite  parallel  to  Poupart's  ligament,  though  it  is  frequently  spoken  of  as 
being  so.  The  structures  divided  are,  the  skin,  the  superficial  fascia,  the  exter- 
nal and  internal  oblique  and  the  transversalis  muscles,  the  transversalis  fascia, 


532 


INCISION'S. 


and  the  peritoneum.  It  has  the  advantage  of  giving  ready  access  to  the 
appendix,  and  of  being  easily  extended  upward  or  downward;  it  is  frequently 
followed  by  hernia,  however,  in  cases  requiring  drainage. 

Roux. — {Rev.    mid.   de  la   Suisse   Rom.,   1890,  torn.    I,  p.  325.)    The   ob- 


I     i     •-  .    - 

:  9  o  a      ■ 


Fig.  243. — McBubnet'b  Incision  (III). 
Showing  the  skin  with  the  externa]  oblique  muscle  retracted,  and  exposing  the  internal  oblique,  which  is 
also  slightly  drawn  apart  in  the  direction  of  the  incision  about  to  be  made,  exposing  the  transversalis  muscle 
below.  The  fibres  are  divided  where  thej  are  longest.  The  important  point  at  this  stage  of  the  operation  is 
to  avoid  injury  to  the  nerve  trunks  readily  found  crossing  the  upper  and  lower  portions  of  the  field.  An  injury 
to  the  muscular  or  cutaneous  branches  of  the  twelfth  nerve  is  followed  by  muscular  paralysis  or  by  an  anesthetic 
area  over  the  zone  indicated.  Injury  to  the  tlio-hypogastric  nerve,  seen  just  above  the  ilio-inguinal,  produces 
similar  disturbances  in  the  lower  zones  of  the  rectus  and  the  skin.  The  arrangement  shown  is  that  most 
commonly  found. 


lique  incision  was  introduced  into  France  by  Roux,  with  a  slight  variation  in 
method  by  which  the  peritoneum,  when  it  is  reached,  is  incised  only  in  the  supe- 
rior external  part  of  the  wound  just  over  the  cecum,  and  not  enlarged  unless 
it  is  necessary  to  do  so. 


McBTJENET  S   INCISION". 


533 


C.  McBurney—  ("Gridiron.")     (Ann.  Surg.,  July,  1894,  p.  38.)     (See  Fig. 
240,  f  f.)     Incision  about  four  inches  long,  crossing  at  right  angles  an  imaginary 

line  drawn  from  the  right  anterior  iliac  spine  to  the  umbilicus,  the  upper  third 
of  the  incision  lying  above  the  line.  (See  Fig.  241,  p.  530.)  The  section  of  the 
external  oblique  muscle  must  correspond  with  that  of  its  aponeurosis,  no  fibres 
being  cut  across.  (See  Fig.  242.)  The  edges  of  the  external  oblique  are  then 
pulled  apart  by  retractors  in  order  to  expose  the  internal  oblique,  whose  fibres, 


- 

03 


Fig.   244.  —  M*  Kt  rm.y's  Incision   (IV). 

Showing  the  excellent  exposure  of  the  cecum  and  structures  adjacent  to  the  appendix.  The  si?e  and  posi- 
tion of  the  opening  can  be  materially  altered  to  meet  changing  conditions,  such  as  an  abnormally  placed  appendix. 
by  traction  in  one  or  another  direction. 


as  well  as  those  of  the  underlying  transversalis  muscle,  are  now  separated  with 
a  blunt  instrument  in  a  direction  parallel  to  their  course,  which  is  nearly  at 
right   angles  to  the  incision  previously  made  in  the  external  oblique.     (See 

Fig.  243.)     Not  more  than  an  occasional  muscle  fibre  n I  be  cut.     The  edges 

of  the  opening  are  then  separated  by  blunt  retractors,  thus  exposing  the  trans- 
versalis fascia,  which  is  divided  in  the  same  line  as  the  muscle.  Finally,  the 
section  of  the  peritoneum  is  made.     The  perfect  exposure  secured  in  this  way 


534 


INCISIONS. 


is  shown  in  Fig.  244.  After  the  appendix  is  removed,  the  wound  in  the  peri- 
toneum is  closed  by  suture;  the  fibres  of  the  transversalis  and  of  the  internal 
oblique  fall  together  as  soon  as  the  retractors  arc  withdrawn,  and  their  closure 
is  made  complete  by  a  couple  of  fine  catgul  stitches.  The  wound  in  the  ex- 
ternal oblique  is  sewed  with  catgul  from  end  to  end.  This  method  was  de- 
vised for  the  purpose  of  obviating  the  occurrence  of  hernia,  a  common  sequela 
after  vertical  or  oblique  incisions.  The  abdominal  wall  owes  its  strength 
largely  to  the  gridiron-like  arrangemenl  of  its  muscular  and  tendinous  fibres, 
and  as  in  this  operation  these  fibres  arc  not  cut,  hut  separated,  their  normal 
arrangement  is  not  disturbed,  and  the  strength  of  the  wall  after  the  operation 


nv\  %  as 


1  to.  245. — Finney's  Incision-. 

Showing  marked  disassociation  of  skin  anil  mu  >  le for  the  purpose  of  protecting  the  deep  wound.     The 

deep  incisions  are  those  which  axe  displaced. 


is  finished  is  almost  as  complete  ; 
possesses  the  additional  advanta 
sion   in   the  skin,  and  little  or 
muscle  fibres  need   he  divided. 
incision  is  shown  in  Fig.  245. 

Incision  in  the  Semilunar 
2.  p.  1360. )  This  is  a  vertical 
region,  following  the  direction 
The  middle  of  the  incision  cor 
of  thi'  surgeon,  the  appendix 
taneous    tissue   are    incised,   am 


ts  if  no  operation  had  been  done.     This  method 

ge  of  causing  no  bleeding  except  from  the  inci- 

iiii  post-operative  pain,  since  no  nerves    nor 

Finney's  modification  of  the  McBurney 

Line.— (Battle,  Brit.  Med.  Jour.,  1895,  vol. 
incision  of  variable  length  in  the  right  iliac 

of    the    linea    semilunaris.      (Sec    Fig.    2  hi.    a.1 

responds  to  the   point   where,   in   the  opinion 

will    be    found.     The    skin    and    the    subcu- 

the   aponeurosis   of   the  external    oblique  is 


SEMILUNAB    INCISION. 


535 


■ 


Ant  aup.sp 


Fig.  246. — Incision  in  the  semilunar  line  (a)  practised  by  Battle.  Kammerer,  Jalapuier.  Lennander  make? 
his  skin  incision,  and  also  that  which  divides  the  anterior  lamella  of  the  rectus  sheath,  0.5  to  2  cm.  median  lo  the 
lateral  border  uf  the  rectus  (b). 


53G 


INCISIONS. 


exposed  as  it  spreads  over  the  rectus  muscle.    The  outer  part  of  the  sheath 

of  tin'  right  rectus  is  then  incised,  and  the  muscle,  having  been  separated  from 
the  sheath  with  the  forefinger,  is  drawn  toward  tin-  median  line.  (See  Fig. 
247.)  On  retracting  the  muscle  the  deep  epigastric  artery  is  seen  lying  on 
its  posterior  sheath,  hut  this  is  easily  avoided.  The  thin  posterior  sheath  of 
the  rectus,  the  sul (peritoneal  tissue,  and  the  peritoneum  are  all  divided  to  the 


Rectus 


<5r  4. 


Inc.  "t h 

(anterior  lamella)*      i 

•      If- 


Inc.  thr.  post.  lam.  of  ^  yj 

sheath  of  rectus 

Deep  epig  • 


■\.n 


Ext. 
.Aponeurosis  of 


M.XI1. 


^\»VVo*.>>-,     V' 


Rectus" 


Flo.  247. — Incision  in  Semilunar  Line  Opening  the  Rectus  Sheath  and  Kxposing  the  Deep  Epigastric 

Vessels  imh.k  the  Retracted  Rectus  .Muscle. 

Note   carefully  the   nerves  exposed   ami   implicated,     'the  subsequent   incision   through    the    posterior   sheath 

of  the  rectus  is  indicated  by  the  vertical  line. 


full  extent  of  the  incision.  After  removal  of  the  appendix,  the  wound  is  closed 
by  interrupted  silk  sutures  in  three  layers  from  behind  forward.  The  pos- 
terior part  of  the  sheath  and  the  structures  behind  the  muscle  are  brought  to- 
gether in  one  line  of  sutures,  after  which  the  rectus  muscle  is  allowed  to  return 
to  its  normal  position.  (See  Fig.  248.)  The  anterior  part  of  the  sheath,  with 
its  external  oblique  aponeurosis,  is  next  sutured,  and  finally  the  subcutaneous 


SKMIIA'XAK    INCISION. 


537 


tissue  and  the  skin.  This  method  has  the  same  advantage  as  that  of  McBurney, 
namely,  the  avoidance  of  hernia  as  a  post-operative  sequela.  It  has  also  the 
same  disadvantage  of  requiring  a  slightly  longer  time  than  the  simpler  opera- 
tions.* 


sversalis 
[nlernal  obi 
gSPi^N  ,.-  Fascia  transv 


Deep  epigastric  vessels 


pel  ifoneum 


Hec+us  abd 

,  Anterior  lamel.la 
;  Poster,  o 


lame(la     1 

r    „\        I  sheath  of  rectus 


Incision 


Linea  alba 


Fig.    248. — Showing  the  Division  of  the  Strata  of  the  Abdominal  Wall  in  the  Incision  over  the  Semi- 
lunar Link. 
The  upper  figure  .shows  the  direction  taken  in  tha  incision,   while  the  lower  shows  the  tissues  divided  and 

retracted 


This  incision  has  also  been  independently  advocated  by  Kammerer  (Ann. 
Surg.,  1S97,  vol.  26,  p.  225);  Jalaguier  (Presse  mal.,  1897,  torn.  5,  p.  53); 
and   Lennander   (Centralhl.  j.  Chir..   1898,   vol.  25,   p.  90). 

*  Battle's  original  publication  in  1895  was  very  brief,  scarcely  more  than  a  note,  and  possi- 
bly for  this  reason  was  almost  entirely  overlooked.  After  the  appearance  of  oilier  claims  he 
published  a  second  paper  describing  bis  method  at  greater  length  {Brit.  Med.  Jour.,  1897, 
vol.  1,  p.  965). 


538  incisions. 

R.  T.  Morris.— i  Short  Incision.)  {Med.  News,  April  7.  1894.)  (See  Fig.  240, 
il  d,  p.  529.)  Incision  11  inches  long  exactly  over  i In-  site  of  the  appendix  in  a 
line  following  the  direction  of  the  external  oblique  fibres.  The  distal  end  of  the 
incision  terminates  at  the  right  margin  of  the  right  rectus  muscle.     After  cutting 

the  skin  the  muscles  and  fascia  are  separated  by  blunt  dissection.  The  trans- 
versalis  fascia  and  the  peritoneum  are  then  picked  up  on  a  1 k.  and  a  guy- 
line  made  of  a  strong  thread  of  catgUl  is  passed  through  them.  A  forceps  is 
then  snapper!  on  the  loose  end  in  order  to  keep  the  guy-line  out  of  the  way, 
and  left  there  until  the  wound  is  closed.  After  the  removal  of  the  appendix  the 
retracted  margins  of  the  divided  transversalis  and  the  internal  oblique  apo- 
neurosis, as  well  as  the  peritoneum,  are  brought  up  into  sight  by  traction  on  the 
guy-line.  They  are  then  closed  with  one  suture  of  catgut  ;  the  guy-line  is  cut 
away,  and  the  external  oblique  with  its  aponeurosis  is  closed  with  one  or  two 
uninterrupted  sutures.  While  the  skin  is  being  closed  it  is  kept  on  the  stretch, 
and  care  is  taken  not  to  include  any  fat  in  the  suture.  The  advantage  of  so 
short  an  incision  is  that  it  reduces  the  length  of  convalescence,  the  patient  being 
in  hed  only  one  ami  a  half  weeks,  and  that  it  leaves  an  almost  imperceptible 
scar;  hut  it  is  unavailable  where  there  is  pus  or  when  complications  are  present. 
The  right  tube  and  ovary  and  the  posterior  surface  of  the  uterus  are  all  that 
can  he  explored  through  this  incision.  The  disadvantages  and  dangers  of  it 
lie  in  the  fact  that  unexpected  conditions  are  very  often  encountered,  and  the 
peritoneum  as  well  as  the  wound  are  seriously  contaminated  before  the  operator 
is  aware  of  the  fact. 

G.  M.  Edebohls.  -(Lumbar.)  (Amer.Jour.Obst.,  1895,  p.  L65.)  (See  Fig.  240, 
h  h.)  This  incision  is  employed  only  when  the  appendix  is  removed  during 
an  operation  undertaken  for  suspension  of  the  kidney.  The  incision  is  the  same 
as  for  a  suspensory  operation,  hut  it  is  extended  farther  down  across  the  loin 
in  the  direction  of  the  anterior  abdominal  wall,  so  as  to  bring  the  anterior  por- 
tion of  the  incision  into  relation  with  the  peritoneal  cavity  and  the  ascending 
colon.  The  peritoneum  is  then  opened  to  the  outside  of  the  ascending  colon. 
This  method  is  never  indicated  except  as  an  accompaniment  to  right  nephro- 
pexy. 

My  own  custom  is  to  use  McBuRNEY's  incision  when  no  pus  is  present, 
as  is  the  case  in  most  interval  operations,  and  Battle's  (semilunar)  incision 
when  an  abscess  must  he  evacuated,  and  there  is  necessity  for  extensive  packing 
with  gauze.  In  exceptional  cases,  when  there  exists  a  mass  of  peculiar  form 
Or  location  and  the  diagnosis  is  uncertain.  I  sometimes  find  it  advantageous 
to  make  two  incisions.  The  first,  which  is  purely  for  exploration,  corresponds 
to  Battle's  incision.  After  finding  the  exact  location  of  the  mass  and  its  rela- 
tions to  the  peritoneum,  a  second  incision  is  made  over  the  mass  or  somewhat 
laterally  to  it.  while  one  hand  is  inserted  through  the  exploratory  wound  for 
guidance.     Before  the  infected  area   is  entered   the  first   incision  is  closed. 

Closure    of   the   Incision. — After  a   perfectly  aseptic   operation   the   inci- 


CLOSURE    OF    INCISION'.  539 

sion  should  be  closed  by  means  of  cumol  catgut  or  fine  silk,  the  tissues  being 
united  layer  by  layer  in  an  order  the  reverse  of  that  in  which  the  incision  was 
made.  The  peritoneum  should  be  closed  by  a  continuous  catgut  suture.  The 
transversalis  muscle  is  rarely  sufficiently  developed  to  call  for  a  special  suture. 
After  this  the  internal  oblique  is  united,  preferably  by  interrupted  sutures. 
The  external  oblique  then  follows,  its  aponeurosis  being  united  by  interrupted 
sutures.  Lastly,  the  skin  wound  is  closed  by  a  continuous  subcuticular  suture 
of  catgut,  silkworm-gut,  or  silver  wire.  In  all  doubtful  cases  it  is  best  to  close 
the  wound  only  in  part,  leaving  an  opening  for  drainage.  The  dictum  of  A. 
^'orcester,  of  Waltham,  Mass.,  uttered  on  this  subject  over  twelve  years  ago, 
is  the  opinion  of  all  experienced  surgeons  to-day :  "Many  a  patient  has 
been  sacrificed  after  an  otherwise  good  operation 
by  the  close  suturing  of  the  abdominal  w  o  u  n  d  "  (Bost. 
Med.  and  Surg.  Jour.,  Aug.  4,  1S92).  C.  P.  Noble  lays  great  stress  upon  the 
overlapping  of  the  tissues  as  an  important  factor  in  the  subsequent  strength  of 
the  abdominal  wall  {Amer.  Jour.  Obst.,  1897,  No.  4). 


CHAPTER  XXV. 
REMOVAL    OF   THE    APPENDIX. 

EXPOSURE    OF    THE    APPENDIX.       TYPICAL    OPERATIONS   FOR    REMOVAL    OF 

THE    APPENDIX.      ATYPICAL    OPERATIONS   FOR    REMOVAL    OF  THE 

APPENDIX.     MECKEL'S   DIVERTICULUM. 

EXPOSURE  OF   THE   APPENDIX. 

The  first  care  of  the  surgeon  after  opening  the  abdominal  cavity  should 
be  to  explore  the  area  surrounding  iho  cecum,  in  order  to  note  the  presence  "1* 
swelling  or  induration,  as  well  as  of  intestinal  or  omental  adhesions.  The 
following  local  conditions  may  give  rise  to  an  error  in  diagnosis: 

A  tumor  of  the  right  ovary. 

Inflammation  of  the  right  ovary  or  tube. 

Extrauterine  pregnancy. 

Worms  in  the  intestinal  canal. 

A  Meckel's  diverticulum. 

A  stone  in  the  righl  ureter. 

A  movable  right  kidney. 

Intestinal  ami  omental  adhesions. 

Stones  in  the  biliary  tract. 

An  error  is  most  likely  to  occur  in  cases  of  right-sided  pain  in  women,  ami 
here  the  first  step  should  always  he  to  examine  the  condition  of 
the  tube  and  ovary  on  the  right  side.  A  movable 
kidney  is  frequently  mistaken  for  an  appendicitis,  and  when  then'  is  no 
visible  affection  of  the  appendix  the  kidney  should  be  grasped  and  the  extent 
of  its  mobility  tested  by  gentle  traction.  'I"he  gall-bladder  will  in 
some  instances  be  found  to  contain  stones  the  removal  of  which  will  clear  up 
the  diagnosis.  I  n  t  e  s  t in  a  1  a  n  d  o  m  e  n  t  a  1  adhesions  should 
always  be  sought  out  ami  separated  if  present.  The  right  ureter  can 
be  inspected  on  the  pelvic  brim  just  to  the  inside  of  the  ovarian  vessels;  if  there 
is  a  stone  at  this  point,  it  can  readily  lie  seen,  and  if  it  is  lower  down,  the  ureter 
will,  as  a  rule,  be  found  dilated.  Round  worms  are  sometimes  felt 
through  the  wall  of  the  small  intestine,  which  can  lie  killed  by  squeezing  or 
needling,  after  which  the  dead  worm  will  be  found  in  the  stool.  A  M  eckel  's 
diverticulu  m  should  be  looked  for  along  the  free  border  of  the  ileum, 
beginning  at  the  valve  and  examining  the  bowel  for  a  distance  of  three  feet 

:,to 


EXP0S1   RE    OF    APPENDIX. 


541 


or  more.  The  symptoms  of  an  inflamed  or  perforated  Meckel's  diverticulum 
are  often  precisely  the  same  as  those  arising  from  an  appendix  similarly  affected. 
In  all  rases  in  which  the  abdomen  is  opened  for  appendicitis  the   appendix 


Fig.  249. — The  Appendix  Concealed  Behind  the  Cecum  and  Flexed  upon  Itself  has  its  Tip  Concealed 

in  a  Retro-peritoneal  Pocket. 
The  ileocecal  fold  terminates  in  the  parietal  peritoneum  over  the  psoas  muscle.      Autopsy  January  24,   1902. 

(Natural  size.) 


must  lie  removed  when  it  can  be  found,  whether  it  appears  normal  or  not, 
for  strictures  and  in  i  n  u  t  e  u  1  c  e  r  a  t  i  o  n  s  of  t  h  e  in  u  c  o  s  a 
may  be  present  which  produce  no  alteration  of  the  peritoneal  surface  recog- 
nizable to  the  naked  eve. 


542 


i;i  Mi  i\  \l.    hi     THE     APPENDIX. 


In  a  favorable  case  the  appendix  may  slip  out  "l"  the  incisional  once: 
if  it  does  not  il<>  this,  it  musl  be  sought  for  by  feeling  with  the  thumb 
and  forefinger,  the  tenia  muscle  serving  as  a  guide  nee  Fig.  249).  Some- 
times, however,  a  hand  passes  from  the  tenia  across  the  cecum,  which 
tends  in  mislead  the  operator  very  seriously  in  looking  for  the  appen- 
dix, should  it  lie  behind  the  cecum  ami  beneath  the  ileum,  as  shown  in 
Fig.  _">n.  Search  should  always  be  directed  to  tin1  iliac  fossa  below  the 
cecum;  then  to  the  pelvic  cavity,  where  the  appendix  may  sometimes  he 
found  hanging  over  the  brim  of  the  pelvis,  or  even  along  it  (see  Fig.  251);  then 
tn  the  inner  side  of  the  cecum  in  the  angle  between  the  cecum  ami  the  ileum: 


I  i>.    250.     Shows  a  Misleading  ' Jonbtricting  Band,  Simulating  i  in.  Antesiob  Husculah  Tenia,  well  Sfiown 

in  the  Right-hand  Lower  Figure. 
By  following  this  band,  the  surgeon  will  l>e  misled  into  searching  for  a  retrocecal  appendix,  when  the  oigan 
he-  a-  seen.      M.  I'.,  at.  twenty-four.     Autopsy  February  1.  1903.     (Two-thirds  natural 


then  t<>  the  outer  side  of  the  cecum  (see  Fig.  252);  ami.  finally,  to  the  posterior 
part  nf  the  cecum.  If  the  appendix  occupies  the  retrocecal  position,  as  it  does 
in  a  large  number  of  cases  (see  Figs.  253  ami  254),  it  is  discovered,  after  the  exclu- 
sion of  other  positions,  by  lifting  up  the  cecum  with  the  tenia  muscles  in  view, 
ami  inspecting  the  point  at  which  the  appendix  disappears  behind  the  bowel. 
If  the  appendix  is  of  the  retrocecal,  extraperitoneal  type,  it  is  then  exposed  to 
view  by  incising  the  cecum  on  its  outer  side,  ami  detaching  the  bowel  from  the 
iliac  fossa  until  the  whole  posterior  surface  of  the  cecum  lies  bared.  An  extreme 
case  of  this  type  is  shown  in  Fig.  255,  in  which  the  appendix  could  only  he  brought 
to  view  by  an  extensive  dissection,  begun  on  the  outer  surface  of  the  cecum  ami 


POC'KKTKIi    APPENDICES. 


543 


colon  and  carried  inward.     Another  unusual  case,  in  which  the  appendix,  although 
intraperitoneal,  lay  completely  to  the  inner  side  of  the  cecum  and  colon,  is  shown 


PlO.  251. — Appendix  Adherent  Across  the  Common  Iliac  Artery  above  the  Promontory  of  no.  Sacrum. 
Note  also  the  relation  of  the  appendix  to  the  ureter  and  to  the  ovarian  vessels.     P.  W.,  col.,  a-t.  seventy-five. 

Autopsy  March    13,    1>99. 


in  Fig.  256  (see  p.  548).  An  interesting  group  of  cases  is  formed  by  ap]>endices 
t  r  a  p  pe d  within  peritoneal  r  e  cesses  a  n  d  p  o  c  k  e  t  s  .  as 
shown  in  Figs.  257  and  258  (see  pp.  549,  550).     Search  fur  the  appendix  must 


Fig.  252. — Embryonic  Displacement  of  the  Appendix,  which  is  BrniEn  is  Adhesions  Uniting  the  Colic 
Flexure  to  the  Gall-bladder,  and  is  bound  down  to  Pre-renal  Peritoneum. 
This  picture  is  invaluable  in  explaining  the  occasional  association  of  appendicitis  with  cholecystitis  and  pye- 
litis.   Autopsy  December  2,  1901.     J.  G.    col.    a-t.  fifty-five.     Carcinoma  of  stomach,  metastases.     (Three-fourths 
natural  size.) 

544 


POCKETED   APPENDICES. 


545 


always  be  carried  on  with  the  utmost  caution,  and  the  operator  should  be 
ever  on  his  guard,  since  the  incautious  lifting  of  a  loop  of  bowel  fir  the 


Ti 


Cecum  and  Colon-  Lifted,  Showing  the  Adhesions  of  the  Terminal  Ileum  and  the  High 
Retro-colic  Appendix,   Kinked  and  Wrapped  in  Veils  of  Adhesions. 
This  case  shows  well  the  difficulties  which  may  sometimes  he  experienced  in  finding  the  appendix.     Autopsy 

January  23,   1902.     (Natural  size.) 


separation  of  some  trifling  adhesion  may  prove  sufficient  to  let  loose  the  con- 
tents of  an  abscess,  hitherto  scarcely  restrained  by  an  insufficient  barrier.     In 
order  that  the  operator  may  carry  clearly  in  mind  the  various  sites  in  which 
35 


546 


REMOVAL   OF  THE   APPENDIX. 


the  appendix  may  be  found,  as  well  as  the  different  attachments,  ae  he  opens 
the  abdomen  to  find  and  remove  it.  a  graphic  present  at  ion  of  these  varving 
positions  is  given  in  Fig.  L',">!l  (see  p.  551). 


Fig.  254. — Snows  tiik  Appendix  Completely  Concealed  from  View  bt  the  Cecum  ano  Colon. 
There  is  a  moderate  decree  of  rotation  of  the  cecum,  which  renders  the  posterior  muscular  band  visible.     This 

may    be    due    to   the   adhe    ion      of    the    ileum    to    the    |>-oa-;    mUM'le    seen    at  la;.      (Natural    size.) 


Operations  for  the  removal  of  the  appendix  may  be  divided  into  two  classes: 

1.  Typical — In  which  tlie  infection  is  localized  in  the  appendix  and  can  be 
readily  isolated  from  surrounding  structures. 

2.  Atypical — (a)   In  which  the  appendix  is  densely  adherent  to  some  other 


APPENDIX    IN    RETKO-MESENTERIC  POCKET. 


547 


Fig.  255. — Showing  ttie  Appendix  Buhied  in  One  of  These  Retro-mesenteric  Pockets. 
The  orifice  of  the  pocket,  in  this  case,  was  completely  occluded  by  adhesions,  and  the  pocket,  within,  was 
completely  obliterated  by  adhesions  to  the  appendix  on  all  sides.  The  peritoneal  coat  of  the  appendix  was  not 
distinguishable.  The  ileocecal  valve  lies  at  (a)  under  the  ileocolic  fold.  The  ileocecal  fold  is  at  (b).  In  order 
to  expose  the  appendix  the  ileum  has  been  lifted  up  to  the  right,  and  an  opening  made  in  its  mesentery.  C.  C, 
col.,  eet.  twenty-six.     Autopsy  December  15,  1902.     (Natural  size.) 


5iS 


REMOVAL    OF   THE    APPENDIX. 


Fig.  256. — The  Normal  Position  is  Shown  in  Right-hand  Lower  Pigi  re, 
The  tip  <>f  the  appendix  lies  a1  poinl  a,  while  the  dntted  lines  mark  the  posil ion  of  the  remainder  "f  the  organ. 
'lli*>  large  figure  show-  the  colon  drawn  aside     ■  as  to  expose  the  retro-mesocolio  appendix.    The  importance  of 
this  ease  in  explaining  deep-seated  concealed  abscesses  cannot  be  overestimated.     Autopsy  January  28,   1892. 
(Natural  -ize.) 


APPENDIX  IN  RETROCECAL  POCKET. 


549 


_, 


Fig.  257. — Thk  Appendix   rbre  Lisa  m  a   Large-moi  ihm>  Rktrocecal  Pocket. 
In  this  case  the  bonier  of  the  omentum  was  adherent  on  the  outer  side  of  the  sac,  and  is  indicated  by  the 


little  remaining  mass.      The  significance  of  this  position  . .t'  ihc  appendix   in   relation  to  abscess  is  evident, 
the  well-developed  appendico-ovarian  ligament  pathologically  produced.     (Natural  size.) 


Note 


550 


i;i.\i'  »val   I  'i     i  hi.    \rri:.\i)ix. 


Fig.  258.     A\   Anti  ao  p Lion   Section  of  the  Preceding. 

ae  depth  of  the  pockel  and  its  narrowing  above,  a    il  extends  high  upundei  I  be  mesocolon.    The 
ileum  has  been  detached  and  t he  ileocecal  valve  is  shown, 


VARI01  S    ATTACHMENTS    OF    APPENDIX. 


55 1 


Fig.  '259. — A  Collective  Picti-re  .Showing  the  Various  Points  of  Attachment  of  the  Vermiform  Appen- 
dix to  Gallbladder,  Kidney,  Abdominal  Wall,  Ileum,  Uterus  and  Adnlxa.  Sigmoid  Flexure,  Blad- 
der, and  a  Hernial  Sac. 


.-).-)_' 


Kl.MOVAl.    OF    TIIK    AI'l'KXUIX. 


structure,  (b)  In  which  the  appendix  lies  behind  the  cecum,  (c)  In  which 
the  disease  of  the  bowel  is  not  limited  to  the  appendix,  bul  involves  the  adjacent 
part  of  tin'  cecum  as  well. 


TYPICAL   OPERATIONS   FOR   REMOVAL   OF   THE   APPENDIX. 

The  one  feature  common  to  all   operations  for  removal  of  the  appendix 
is  the  ligation  of  the  mesappendix  so  as  i"  control  the  vessels.     This  ligation 


Line  of  divtiion  betw.  arterial  arc  of  ercum  and  apc?ncii». 


l  i...  260. — The  Cohhonesi   Ttpe  of  Circulation  at  the  Appendico-cecai<  Angle. 
Follow  the  dotted  line  which  indicates  tin-  division  between  tin-  cecal  and  appendical  vessels  in  this  and  the  follow- 
ing diagrams.     The  dotted  Line  represent  -  tin-  maximum  area   [62  per  cei 


"} 


Fig.  261. — Normal  Type,  Non-adherent  Appendix. 

The  circulation  is  best  controlle  1  by  locating  the  vessels  in  the  mesappendix,  and  then  ligating  only  the  main  trunks 

which  supply  the  appendix,  sparing  any  important  branch  going  to  the  cecum,  as  shown  in  the  diagram. 


begins   on   the   free  border,   so   as  to   control    the    vessels    of    the    mesentery 
ami    is    continued    onward    as   far   as   the    ceco-appendical    angle,    a    little 


LIGATION    OF    MESAPPEXDIX. 


553 


on  to  the  surface  of  the  appendix.  It  is  important  for  the  surgeon  to 
familiarize  himself  with  the  varying  conditions  in  the  vascularization  of 
the  appendix  and  the  adjacent  cecum,  in  order  that  the  ligatures  may 
be  applied  so  as  to  control  the  hemorrhage,  and  at  the  same  time  avoid 
cutting  off  the  circulation  of  any  portion  of  the  cecum.  The  line  of  division 
between  the  arterial  supply  of  the  cecum  and  of  the  appendix  in  62  per  cent, 
of  the  cases  is  found  well  out  on  to  the  cecum  (see  Fig.  260).     It  is  manifest 


l  Line  of  di v  bet*,  art.  circ   of  cecum  rwid  appendix 

Fig.  262. — The  Appendical  and  Cecal  Systems  are  here  Entirely  Disassociated  (32  j»er  cent.). 


/  Lne  of  3iy  betw  ~".  -  re  of  c 


>f  cec  ir6  aop.. 

Fig.  263. — The  Cecal  Vessels  here  Supply  the  Root  of  the  Appendix  (5  per  cent.). 


that,  for  this  reason,  it  is  of  advantage  not  to  tie  all  the  appendical  vessels  at  too 
high  a  point.  Fig.  261  shows  the  best  methods  of  ligating  in  such  a  case,  sparing 
the  last  cecal  artery,  and  thus  insuring  a  maximum  nutrition  to  the  parts  during 
the  healing  process.  In  32  per  cent,  of  the  cases  the  circulation  is  neatly  divided 
at  the  base  of  the  appendix  (Fig.  262).  and  here  the  ligature  may  be  applied  high 
enough  to  give  perfect  control  of  all  the  vessels.  Again,  in  5  per  cent,  of  the  ca^es 
we  have  a  condition  in  which  the  cecal  artery  supplies  the  proximal  portion  of  the 
appendix  (Fig.  263).     It  is  in  such  cases   that  we  must  be  on  our  guard  against 


554 


Kl,\lu\  \l.    OF    THE     APPENDIX. 


bleeding  after  amputation,  and  especially  for  the  occasional  case    see  Fig.  264) 
in  which  there  is  a  broad  arterial  anastomosis  between  the  cecal  and  the  appendi- 

cal  vessels  in  the  little  mesentery. 


Fig.  264  — Broad  Abterial  Anastomosis  in  imi  Mesappenddc   (I  per  cum  i 


Fig.  265. — Fhowin-g  the  Method  of  Controlling  the  Circulation  when  the  Mesappendtx  is  Bound  Down. 

The  ligatures  must  here  control  the  individual  vessels  close  to  t he  appendix. 

It  sometimes  happens  that  the  mesappendix  is  so  short  that  the  main 
trunks  cannot  he  exposed  above;  in  such  cases  it  will  lie  necessary  to  tie  the 
vessels  singly  (a  procedure  some  surgeons  elect   by  preference)   close  to  the 


TREATMENT    OF    STUMP    OF    APPENDIX.  OOO 

appendix,  as  shown  in  Fig.  265.  When  the  appendix  lies  to  the  outer  side  of 
the  cecum,  and  the  mesenteriolum  is  closely  attached,  as  shown  in  Fig.  266, 
it  is  always  safer  to  control  the  terminal  vessels  close  to  the  appendix,  pro- 
ceeding, as  a  rule,  from  tip  to  base. 

In  dealing  with  the  stump  of  the  appendix  it  is  important  to  avoid  two  things, 


Fig.  '_'»if>. — Showing  the  Control  of  the  Vessels  in  the  Case  of  an  Appendix  Adherent  h  >  rHE  Outer  Sur- 
face of  the  Colon. 


Fir,.  267. 

A  diagram,  after  Edebohls,  to  show  the  danger  of  burying  i  lit-  exposed  mucous  membrane  of  the  ^tuinj>  bottled  up 

in  a  recess  of  t lie  peritonea]  cavity. 


first,  the  simple  1  i  g  a  t  i  0  n  a  n  d  a  mputation,  1  e  a  v  i  n  g  t  h  e 
m  u  c  o  u  s  in  c  m  b  r  a  n  e  exposed,  w  h  e  t  h  e  r  steriliz  e  d  o  r 
not  ;  second,  a  method  which  has  been  frequently  practised  (sec  Fig.  L'(>7). 
namely,  that  of  ligating,  a  m  put  a  t  i  n  g  ,  a  n  d  b  u  r  y  inn  t  h  e 
little     stum  p    li  y    m  pans    of    sero-serous    sutures.      This 


556 


RKMOVAI.    OK    THE    APPENDIX. 


proceeding  lias  in  more  than  one  instance,  been  the  source  of  Berioua  post- 
operative sequelae. 

The  earliest  methods  of  treating  the  appendix  are  now  obsolete,  ami  no  one 


^■■^gw 

■^^■■■■J 

f 

■ 

- 

J 

1  I'-      268.  —  I,    A    SlMl-l.K,     WlDELY-USED    METHOD    "I     l.x-Mll"\    t.y    ihi.    APPENDIX. 

■  entery  is  ti&l  off,  a  circular  suture  placed,  and  the  appendix  clamped,    'See  , 


Fio.  26ft. — II,  The  Stomp  of  the  Appendix  is  then  Grasped  with  Forceps  and  Thrust  into  the  Bowel. 

(See  p.  558.) 

to-day  would  think  of  trimming  off  and  closing  the  rough  edges  of  a  perforation, 
as  in  1887,  or  even  of  simple  ligation  and  excision  without  sterilization,  as  in 
1888. 

A  number  of  improved  methods.for  removal  of  the  appendix  in  simple  uncom- 


VARIOUS    METHODS    OF    REMOVAL. 


557 


plicated  cases  are  now  in  use.     These  typical  operations,  however  different  in 
detail,  may  be  classified  into  the  following  groups : 

1.  Ligation,  excision,  and  sterilization  with  projection  of  stump. 


Fig.  270. — 111,  At  the  Same  Time  the  Circular  Suture  is  Tightened  and  Tied,  After  Which  the  Forceps 

is  Withdrawn.     (See  p.  558.) 


Fig.  271. — IV,  Final  Step  Showing  the  Placing  of  the  Mattress  Sutures  over  the  Circular  Suture. 

(See  p.  559.) 

2.  Ligation,  excision,  and  sterilization,  with  depression  of  stump. 

3.  Inversion  of  stump. 

4.  Inversion  of  the  entire  unopened  appendix. 


:,:,s 


REMOVAL    OF    THE    APPENDIX. 


5.  Amputation  flush  with  the  cecum. 

(I.  Amputation  by  means  of  the  cautery. 

A  simple,  satisfactory  method  of  removing  the  appendix  is  that  repre- 
sented in  Figs.  268  to  271  ("see  pp.  .")">(>,  ">.">7j.  In  these  figures  the  mesap- 
pendix  is  tied  off  down  to  the  angle.     A  circular  suture  of  silk  or  chromicized 


Fig.  272. — Shows  the  Method  of  Freeing  the  Amputation  Area  of  all  its  Contents  and  the  MUCOSA,  as 

used  hy  Finney. 
The  appendix  is  clamped  and  the  forceps  then  worked  up  and  down,  producing  the  thin  strip  of  tissue  seen 
in  the  right-hand  figure.     This  may  be  ligated,  the  appendix  amputated,  and  the  stump  inverted  under  the  cir- 
cular ligature.     A  modification  of  this  plan  is  to  turn  back  a  cuff  before  clamping. 


catgut  is  then  laid  in  the  cecum  near  the  base  of  the  appendix,  transfixing 
the  mesentery  if  necessary.  The  appendix  is  then  grasped  with  forceps  and 
amputated,  about  1  cm.  from  the  cecum.  The  cautery  may  be  used  in  making 
the  amputation.  If  the  knife  is  used,  the  end  of  the  stump  should  be  sterilized 
with  carbolic  acid.  The  stump  is  then  grasped  with  a  pair  of  forceps  (see  Fig. 
269)  and  pushed  into  the  cecum  as  the  circular  suture  is  tied  (Fig.  270).     The 


halsted's  method  of  REMOVAL. 


559 


wound  area  is  then  buried  under  two  or  three  mattress  sutures  and  the  mesen- 
teriolum  covered  in  by  a  continuous  fine  silk  suture  (Fig.  271;. 

In  order  to  render  the  appendix  perfectly  pliable  at  the  point  of  amputa- 
tion, Finney  uses  the  plan  of  crushing  it  near  the  base  with  a  pair  of  forceps, 
and  then  working  the  forceps  up  and  down  so  as  to  free  the  interior  of 
the  appendix  of  its  mucosa.      This   plan   produces  a  narrow  strip  of  tissue 


Fig.  273. — Halsted's  Three   Clamp   Method   of   Removal.      First   Step. 
The  circular  suture  is  placed  as  shown;  the  three  clamps  are  then  applied,  the  middle  one  first. 


which  may  he  ligated  (Fig.  272)  and  inverted  into  the  cecum  while  a  circular 
suture  is  tied. 

Another  method,  constantly  used  in  the  surgical  department  of  the  Johns 
Hopkins  Hospital,  is  that  of  the  three  clamps;  applied  as  shown  in  Figs.  273  and 
274;  first  the  middle  clamp,  then  the  one  above,  and  then  the  one  below.  Upon 
removing  the  middle  clamp,  a  narrow  strip  of  compressed  tissue  is  exposed  for 
amputation  with  knife  or  cautery. 


560 


RKMOVAI.    OK    THE    Al'l'I'.XDIX. 


Other  methods  as  used  by  different  surgeons  arc  as  follows: 

C.  Beck  i.V.  )'.  Med.  .I<>nr.,  Dec.  LO,  1898).    After  squeezing  the  contents 


Fir:.  274.     Halstbo'b  Thbbs  ("lamp  Msthod,  Second  Stbp. 

The  middle  clamp  is  removed,  the  ribbon  burned  through  with  1  lie  cautery,  and  the  stump  inverted.     The  knife 

may  l»e  u*e<l  in  place  of  the  cautery*  taking  care  to  sterilise  the  end  of  the  stump  with  carbolic  acid. 


Fia.  275. — Beck's  Method  OF  Dealing  with  the  Stttmp. 

Catgut  ligatures  thrown  around  the  liberated  base  of  t he  appendix  and  the  mucous  membrane  excised  as  shown. 

The  musculo-serous  flap  is  then  united  by  three  Lembert  sutures. 

of  the  appendix  into  the  cecum,  a  catgut  ligature  is  tied  round  the  base  of  the 
organ,  ami  a  similar  ligature  is  applied  half  a  centimetre  below  the  first.  The 
appendix  is  then  amputated  with  scissors,  close  above  the  lower  ligature ;  the  exit 


riedel's  method  of  removal.  561 

of  any  fecal  matter  being  prevented  by  the  previous  squeezing  and  tying.  The 
protruding  mucous  membrane  of  the  appendix  is  first  disinfected  with  a  strong 
solution  of  bichloride  of  mercury,  then  seized  with  an  artery  forceps,  pulled  out  as 
far  as  possible,  and  cleanly  cut  off  with  the  scissors,  the  remnant  being  dusted 
with  iodoform  powder  (Fig.  275).  A  muscular  serous  flap  is  thus  left,  which  can 
easily  be  united  with  Lembert  sutures.  Dusting  the  little  wound  margins, 
which  are  to  be  united,  with  iodoform  is  to  be  carefully  avoided. 

Riedel  {Bed.  klin.  Wochen.,  1899,  p.  749;  also,  Ccntralbl.  f.  Chir..  1903,  Bd. 


Fig.  276. — Fowler's  Ccff  Method.     First  Step. 

Mesappendix  divided:   a  temporary  ligature  at  the  ba.se  and  a  ligature  beyond  to  close  the  appendix.     A  circular 
incision  between  the  ligatures  dividing  only  the  outer  coats.     (See  p.  562.) 

30,  p.  1339).  The  mesenteriolum  of  the  appendix  is  tied  off  down  to  the  cecum. 
The  cecum  is  then  freed  of  all  fatty  tissues  around  the  base  of  the  appendix, 
which  is  ligated  with  catgut  close  to  the  cecum,  and  again  with  silk  1  cm.  from 
the  catgut  ligature.  The  appendix  is  divided  and  removed  between  the  ligatures. 
The  accessible  mucosa  of  the  stump  is  now  cut  away  with  scissors  curved  on  the 
flat,  after  which  the  serosa  and  the  muscularis  are  united  with  three  interrupted 
silk  sutures.  The  catgut  ligature  is  now  cut  and  removed.  Close  to  the  three 
silk  sutures,  five  other  silk  sutures  are  passed  through  the  serosa  and  muscu- 
laris of  the  cecum,  in  such  a  manner  as  to  turn  in  the  little  stump  and  approxi- 
36 


562 


REMOVAL    OK    TIIK    A1TKXD1X. 


mate  the  scnuis  surfaces  over  an  area  a  good  centimetre  in  breadth.  Sometimes 
Riedel  applies  a  third  row  of  six  or  seven  catgut  sutures,  which  turn  in  the 
appendix  stump  still  further. 

G.  R.  Fowler  (Circular  Flap  Method)  (Treatiseon  Appendicitis,  L894,  p.  L62). 
A  temporary  ligature  is  thrown  around  the  base  of  the  appendix  close  to  the 
cecum,  and  twisted  until  it  constricts  the  organ  sufficiently  to  prevent  (lie 
escape  of  fecal  matter.  A  second  ligature  is  applied  about  half  an  inch  from 
the  first,  and  tied.  A  circular  incision,  including  the  serous  coat  and  the  sub- 
serous connective  tissue,  is  now  made  in  the  space  between  the  two  ligatures 
(Fig.    276).     A  cuff-shaped    flap   formed    of   these   structures    is    turned    buck 


Fig.  277. — Fowler's  Method,  Second  and  Third  Steps. 

Upper  figure,  the  cuff  stripped  back,  a  ligature  applied  at  the  base,  and  the  appendix  removed  close  to  ligature 

at  arrow.     Lower  ligure,  short  stump  sterilized. 


toward  the  temporary  ligature,  and  another  ligature  of  fine  ordinary  catgut 
(which  has  not  been  hardened)  is  placed  around  the  wall  of  the  appendix  at  the 
bottom  of  the  reflected  cuff  of  serosa  and  within  it.  This  ligature  is  tied 
tightly,  and  cut  off  close  to  the  knot  (Fig.  277).  The  appendix  is  now 
amputated,  and  the  mucous  membrane  of  the  stump  touched  with  the  ther- 
mocautery or  with  fuming  nitric  acid.  The  cuff-shaped  flap  is  next  placed 
over  the  face  of  the  stump,  which  is  then  grasped  by  a  pair  of  dissecting 
forceps  and  crowded  against  the  wall  of  the  cecum  in  such  a  manner  as  to 
form  a  furrow  or  depression  in  it  (Fig.  278).  The  edges  of  the  cecum  are 
sutured  over  the  stump  of  the  appendix  by  means  of  a  double  row  of  Lembert 


dawbarn's  method  of  removal.  563 

sutures,  so  disposed  that  the  stump  is  buried  out  of  sight.  In  two  or  three 
days  the  ligature  about  the  wall  of  the  appendix  gives  way,  but  in  the  mean- 
while the  sutured  edges  of  the  furrow  have  become  strongly  adherent,  so  that 
there  is  no  danger  of  escape  of  the  contents  of  the  intestines. 

R.  H.  M.  Dawbarn  (Internal.  Jour.  Surf/..  May,  1895).  The  appendix  is 
surrounded  by  a  purse-string  suture,  three-fourths  of  an  inch  from  its  base,  and 
the  first  half  of  a  surgeon 's  knot  is  made  ready,  but  not  tightened.     The  appendix 


Fig.  278. — Fowler's  Mfthoi>,  Fotrth  Stfp. 
Closure  of  cuff  over  stump. 

is  then  divided,  leaving  a  stump  of  variable  length,  but  never  shorter  than  half 
an  inch.  A  pair  of  forceps  with  closed  blades  is  introduced  through  the  stump 
into  the  cecum,  the  blades  opened,  and  the  calibre  of  the  stump  stretched  so  as 
to  overcome  any  stricture  (Fig.  279).  The  extreme  free  end  of  the  stump  is 
then  seized  by  a  similar  pair  of  mouse-toothed  forceps  and  the  stump  invag- 
inated  like  a  glove  finger.  When  this  proceeding  is  accomplished,  the  forceps 
and  the  appendix  are  one-half  an  inch  inside  the  cecum.     The  purse-string  is 


564  REMOVAL   OF   THE    APPENDIX. 

now  tightened,  and  while  this  is  being  done,  the  forceps  are  withdrawn.  This 
method,  which  is  very  rapid,  lias  the  further  advantage  of  doing  away  with 
the  evil  of  approximating  infected  surfaces,  since  it  brings  two  peritoneal  sur- 
faces into  contact. 


Fig.  279. — Dawbarn's  Method. 
A  purse-string  ligature  is  applied  around  the  appendix  J  of  an  inch  from  the  base.     The  appendix  is  then 
amputated,  and  the  stump  stretched  with  a  pair  of  forceps  (a)  as  shown      This  facilitates  the  inversion, which 
i    effected  by  clasping  the  cut  edges  with  a  pair  "f  delicate  forceps  and  turning  the  stump  into  the  cecum,  as  shown 
in  the  right-hand  figure,     b,  b',  is  a  window  cut  in  the  cecum  to  show  the  inverted  appendix. 

M.  W.  Herman  (CentraM.  /.  Chir.,  1901,  Bd.  28,  p.  1026),  under  the  title 
"Zur  Technic  der  Skolikoidektomie,"  cites  a  case  in  which  an  abscess  developed 
in  the  little  dead  space  between  the  end  of  the  amputated  and  ligated  ap- 
pendix and  the  sero-serous  sutures    which    buried  it  in  the  cecal  wall.     The 


EDEBOHLS   METHOD  OF  REMOVAL. 


.-,<,;, 


details  of  the  autopsy,  unfortunately,  arc  not  Riven.  On  account  of  this 
experience  the  plan  was  adopted  in  Rydygier's  clinic  of  inverting  the  stump 
of  the  appendix,  amputated  a  few  millimetres  above  its  base,  into  the  cecum, 
and  closing  the  opening  by  two  rows  of  sero-muscular  sutures;  an  operation 
not  dissimilar  to  Dawbarn's. 

G.  M.  Edebohls  (Amer.  Jour.  Med.  Sri.,  June.  1S05).  The  appendix  is  sepa- 
rated from  its  mesenteriolum.  and  cleanly  freed  from  all  surrounding  tissues  down 
to  its  cecal  origin.  A  strand  of  fine  silk  or  chromicized  catgut  is  next  passed 
through  the  peritoneal  investment  of  the  caput  coli,  as  close  as  possible  to  the  point 


Fig.  280. — Edebohls'  Method  of  Inverting  the  Appendix. 

A  strand  of  chromicized  catcut  is  inserted  as  shown  and  used  in  t lie  inversion  of  the  appendix,  which  is  gradually 

effected  with  fingers  and  forceps  as  shown  (a).     l>  shows  the  same  in  cross-section. 


of  origin  of  the  appendix,  either  alio ve  or  below.  The  assistant  then  gently  grasps 
the  caput  coli  with  the  index  finger  and  the  thumb  of  one  hand  just  above 
the  appendix,  and  with  those  of  the  other  hand  just  below  it  (Fig.  280).  This 
brings  the  opening  through  which  the  appendix  is  to  be  inverted  between  the 
fingers  of  the  two  hands.  The  operator  then  seizes  the  appendix  near  its  base 
with  thumb  forceps,  and  inverts  iis  proximal  part.  The  portion  inverted  is 
held  in  place  by  a  finger  of  the  other  hand,  or  by  a  second  forceps,  v  li  '  the  first 
forceps  grasps  another  portion  of  the  appendix  and  pushes  it  in  after  the  first, 
this  process  being  repeated  until  at  last  the  tip  of  the  appendix  is  pushed  inside 


566 


REMOVAL   OF   THE    APPENDIX. 


of  the  peritonea]  mouth.  The  operator  grasps  the  lips  of  the  opening  through 
which  the  appendix  has  disappeared  with  the  thumb  and  forefinger  of  one  hand. 
Willi  the  fingers  of  the  other  hand  he  feels  for  and  seizes  the  now  half  inverted 
appendix  through  the  coats  of  the  caput  coli,  and  by  appropriate  manipulation  di- 
rected from  the  origin  toward  the  free  end,  the  Bemi-inversion  is  soon  converted 
into  a  complete  one  1 1  -'ig.  281).  The  exact  momenl  when  inversion  is  accom- 
plished is  readily  recognized  by  the  fingers.  The  peritoneal  orifice  is  closed  by 
continued  sutures.  This  method  has  the  advantage  of  keeping  the  abdominal 
cavity  free  from  foreign  material  by  doing  away  with  the  necessity  for  opening 
the  appendix  and  suturing  it. 


Fig.  281. — Edebohls'  Method,  the  Inversion  Completed. 
Edebohls  closes  the  inversion  by  a  running  Lembert  or  a  puise-string  suture. 


R.  T.  Morris  (Lectures  on  Appendicitis,  1896,  p.  59).  The  muscular  and  serous 
coats  of  the  appendix  are  divided  in  a  circle  close  to  the  cecum,  leaving  the 
mucous  coat  untouched.  This  inner  coat  is  then  ligated  with  a  strand  of  line 
eye  silk,  anil  the  appendix  amputated.  The  peritoneal  surfaces  of  the  stump 
are  scarified,  after  which  it  is  depressed  and  buried  by  bringing  the  walls  of  the 
cecum  together  over  it  with  three  or  four  Lembert  sutures. 

J.  B.  Deaver  (Ann.  Surf/.,  1898,  vol.  27.  p.  79).  After  the  appendix  is  in 
the  grasp  of  the  thumb  and  finger,  the  cecum  is  replaced  within  the  abdominal 
cavity.  The  appendix  is  then  amputated  flush  with  the  cecum,  and  the 
opening   in    the  latter  closed  with  Lembert  sutures  (Fig.  282).     This  method 


Skene's  method  of  removal. 


507 


is  also  recommended  by  A.  Zelleu  (Centralbl.  /.  Chir.,  1902,  Bd.  30,  p.  121), 
as  obviating  all  risk  of  infection  from  the  stump. 

A.  J.  C.  Skene  f.V.  Y.  Med.  Jour.,  March  5,  1898).  The  description  of  this 
method  as  it  was  first  performed  is  ns  follows :  The  forceps  was  applied  upon  the 
mesappendix  close  to  its  mesenteric  attachment.  A  current  which  heated 
the  forceps  to  180°  F.  was  then  induced  for  half  a  minute.  Upon  removing  the 
forceps  the  tissues  were  found  not  to  be  charred,  but  dried,  having  the  appear- 
ance of  white  horny  matter.    The  desiccated  area  was  then  bisected  with  scissors. 


Fig.  282. — Deaver'9  Method  of  Amputating  the  Appendix  Flush  with  the  Cecum  and  Closing  with  Mat- 
tress or  Lkmheht  Sutures. 


A  second  seizure  was  then  made,  this  time  upon  the  appendix  itself,  close  to 
the  caput  coli,  after  which  the  same  current  was  induced  and  continued  for  ninety 
seconds.  The  forceps  was  then  removed,  and  the  tissue  divided  in  the  line  of 
the  desiccated  area,  away  from  the  caput.  The  same  result  as  before  was  appar- 
ent, namely,  no  charred  tissue,  no  bleeding,  and,  more  important  than  all,  no 
escape  of  the  contents  of  the  appendix.  The  tissues  had  been  simply  dried  out. 
Just  at  this  point  a  rather  violent  attack  of  retching  came  upon  the  patient, 
which  continued  for  nearly  a  minute,  without  inducing  any  change  whatever  in 
the  stump.      Even  the  severe  pressure  and  strain  thus  occasioned  failed  to  force 


;>.,x 


KKMOVAL  OF  THE   APPENDIX. 


Fin.    2.KX.  —  Downks'    M  KTHI  if. 

The  base  of  the  appendix  is  converted  into  a  flat  translucent  cord    by  Dowries'  electrothermic  angiotribe. 
The  right-hand  figure  shows  the  appearance  <>f  the  ti    lie     the  mesappendix  divided   and  the  appendix  aboul 

to  be  amputated  in  the  directiuii  of  the  arrow,  as  shown  by  the  left-hand  lower  figure.      (.See   p.    572.) 


KELLY S  METHOD  OF  REMOVAL. 


5G9 


Fig.  284. — H.  A.  Kelly.     Crushing  Forceps,  Half  Natural  Size,  with  Groove  for  Contact  with  Caitkrt 
Point  for  Cooking  the  Stump  and  Converting  it  into  a  Translucent  Band. 


Fig.  285. —  H.  A.  Kelly's  Method  I.  Thr  Mesappfxdix  is  Ligated  and  Divided.  A  Circular  Suture 
<>k  Mattress  Sutures  are  then-  placed  ready  to  turn  in  the  Stump.  The  Appendix  is  then 
Crushed  near  its  Base  with  Powerful  Grooved  Forceps  and  held  away  from  the  Cecum  by 
the  wet  Gauze.     It  is  then  slowly  Amputated  with  the  Cautery.     'See  p.  572. J 


570 


REMOVAL  OF  THE   APPENDIX. 


Fig    2SG. —  Kelly's    Methoi>.      II.  Tin-:  LtTTLB  TRANSLUCENT  Stump  is  then  Simply  Invaginated  into  the 
Cecum  by  the  Circular  Suturr.     (See  p.   572.) 


Fig.  287. — Kelly's  Method.     III.  The  Operation  Completed.     (See  p.  572.) 


EASTMAN  S    FORCEPS    FOR    REAIOVAL    OF    APPENDIX. 


571 


Fig.  288.— Eastman's  Method. 
Showing  the  appendix  grasped  at  its  base  by  a  pair  of  forceps  armed  with  detachable  shields  which  serve  to  pro- 
tect the  adjacent  bowel  and  catch  any  secretions.     (,See  p.  572.) 


572 


REMOVAL    OF    TIIK    APPENDIX. 


a  drop  of  blood  or  serum  into  the  compressed  area.  The  wound  was  closed  with- 
out the  necessity  of  introducing  any  foreign  body  in  the  shape  of  suture  material 
into  the  abdominal  cavity.  The  pat  nut  made  an  uninterrupted  recovery. 
The  method  just  described  has  only  become  generally  available  since  the  inven- 
tion of  A.  J.  I  (ownes'  admirable  electro  thermic  crushing  forceps,  which  are  shown 
in  the  illustration  with  full  description  in  the  legend  (see  Fig.  283,  p.  568). 

H.  A.  Kelly.  My  own  method  is  that  of  crushing  the  base  of  the  appendix 
with  a  pair  of  powerful  forceps  (see  Fig.  284),  and  then  slowly  amputating  it 
with  the  Paquelin  cautery  at  a  bright  red  heat,  taking  from  thirty  to  forty-five 


Fig.  289. — Lennanper's   Method.    Fin«T  Stfi* 
The  mesappendix  is  cut  and  a  temporary  Ligature  applied  :ii  the  base  of  the  appendix,  which  is  then  clamped  die- 
tally  and  amputated   with   the  cautery.      (See  p.  575.) 


seconds  in  the  process.  The  distal  end  of  the  appendix  should  be  clamped  to 
prevent  the  escape  of  its  contents  (Fig.  285).  \W  keeping  the  cautery  in  close 
contact  with  the  forceps,  which  is  beveled  for  this  purpose,  the  latter  is  con- 
verted into  a  heating  iron,  and  thoroughly  cooks  the  little  stump,  firmly  sealing 
it,  and  converting  it  into  a  translucent  ribbon  of  tissue,  after  which  it  is  invag- 
inated  into  the  cecum  (Fig.  286),  and  the  circular  suture  drawn  up  covering  the 
wound  area  (Fig.  287).  It  is  safer  to  add  a  row  of  sero-serous  mattress  sutures 
over  this. 

J.  R.  Eastman  (Jour.  Amer.  Med.  Assoc,  Oct.  11,  1002).     Eastman  uses 


Fig.  290. — Lennander's  Method,  Second  and  Third  Steps. 

The  mucosa  of  the  stump  is  sterilized  with  the  cautery,  as  shown  in  the  upper  figure  after  which  the  outer  coats 

are  carefully  approximated  by  suture,  and  the  temporary  ligature  is  then  removed.     (See  p.  575. J 


Fig.  291. — Lennander's  .Method,  Fourth  Step. 

The  inversion  of  the  stump  by  mattress  sutures.     If  the  closure  is  unsatisfactory,  the  ileocecal  fold  is  resected 

above  and  drawn  over  the  wound  area.     Its  vascularization  comes  from  below  and  is  not  interfered  with. 

573 


:.7I 


REMOVAL    OF   THE    APPENDIX. 


cystic  portion   of    App. 


Fig.  292. — Cullen's  Case. 
Cystic  appendix  attached  to  omentum;  the  latter  is  thickened  and  contains  numerous  colloid  areas,  also  seen 
on  cross-section,  a,  a.     Removal  of  appendix,  double  ovariotomy.     L.  M.,  set.  fifty-seven.     Church  Home,  May 
25,  1903.     (Natural  size.) 


REMOVAL    OF    ADHERENT    APPENDIX.  575 

a  pair  of  artery  forceps,  armed  with  detachable  shields,  for  the  purpose  of  facil- 
itating the  amputation  of  the  appendix  with  the  cautery.  The  shields  are  light 
and  slip  on  and  off  the  blades  of  the  forceps  with  ease  (Fig.  288,  p.  571). 

Lennander  (Rev.  de  gynec.  et  cle  chir.  abdom.,  Sept.-Oct.,  1900).  In  this 
method  the  cautery  is  used  in  the  following  manner.  All  adhesions  arc  freed  as 
far  as  possible  and  the  appendix  ligated  close  to  the  cecum  with  a  temporary 
ligature.  It  is  then  clamped  a  little  beyond  this  ligature  with  forceps  (Fig.  289, 
p.  572),  and  amputated  with  a  cautery.  The  projecting  mucosa  is  thoroughly 
sterilized  (Fig.  290),  and  the  sero-muscular  edges  of  the  stump  are  brought 
together  with  a  continuous  suture  of  silk.  After  this  the  little  stump  is  inverted 
and  buried  by  one  or  two  rows  of  mattress  sutures  (Fig.  291).  An  important 
point  is  the  occasional  use  of  the  ileocecal  fold  to  cover  in  the  same  area. 


ATYPICAL   OPERATIONS   FOR   REMOVAL  OF  THE   APPENDIX. 

Adhesions. — In  a  case  of  appendicitis  complicated  by  adhesions  it  is  of  the 
utmost  importance  to  avoid  injury  to  the  coats  of  the  adherent  intestines. 
One  of  the  simplest  complications  is  that  of  omental  adhesions,  in  which  the 
diseased  part  of  the  appendix  is  not  infrequently  found  enveloped  in  the  free  bor- 
der of  the  omentum,  which  acts  as  a  protecting  barrier,  effectively  limiting  the 
spread  of  the  disease.  In  all  such  instances  the  safest  plan  is  to  remove  the 
omentum,  with  the  appendix,  by  excising  as  large  a  piece  as  may  be  necessary, 
and  then  amputating  the  appendix  as  it  lies  undisturbed  in  its  omental  blanket 
(see  Fig.  292).  In  the  case  shown  here  an  unusual  amount  of  the  omentum  was 
removed  on  account  of  numerous  cysts  in  its  substance. 

One  of  the  simplest  forms  of  adhesions,  which  is  also  one  representing  a  conser- 
vative effort  on  the  part  of  nature  to  shut  off  the  peccant  organ,  is  the  forma- 
tion of  a  net  of  adhesions  uniting  the  ileum  to  the 
cecum  ,  and  pocketing  the  diseased  appendix  below  (see  Fig.  293).  In  the 
removal  of  such  an  appendix  it  is  only  necessary  to  pack  off  on  all  sides  with 
great  care,  and  then  to  cut  through  the  tent  wall,  and  to  liberate  and  excise 
the  organ. 

When  the  diseased  appendix  is  densely  adherent  in  its  distal  portion  it  is 
a  good  plan  to  expose  its  base,  and  then  detach  it  in  such  a  manner  as  to  free  the 
appendix  from  the  cecum.  The  distal  freed  portion  is  then  wrapped  in  a  piece 
of  gauze  for  protection,  while  the  opening  into  the  bowel  is  closed  by  whatever 
method  the  operator  prefers.  After  this  has  been  done,  the  adherent  end  of 
the  appendix  can  be  dissected  out  of  its  bed  with  far  greater  facility  than  was 
possible  when  both  extremities  were  anchored,  the  one  to  the  cecum  and  the 
other  by  the  adhesions;  the  precaution  of  surrounding  the  matted  mass  on  all 
sides  with  gauze,  before  handling  it,  and  so  risking  the  rupture  of  an  abscess, 
must  never  be  omitted.     This  plan  is  especially  suited  to  the  gynecologic  field. 

\Y  hen    the    whole   appendix   lies   imbedded   in   strong 


576 


REMOV  \l.    OK   THE    APPENDIX. 


old  adhesions,  and  can  be  removed  only  by  digging  it  oul  of  its  bed,  there 
is  considerable  risk  of  tearing  the  adjacent  structures,  or  of  exciting  hemorrhage 
by  rupturing  one  of  the  numerous  small  vessels,  which,  being  situated  in  the 
midsl  of  (lie  matted  tissues,  arc  difficull  to  control.  In  all  such  cases  ii  is  a 
good  plan  to  detach  the  base  of  the  appendix  as  just  described  (or  as  shown 
in  Figs.  294  anil  295),  ami  then,  catching  the  freed  end  with  a  pair  of  artery 
forceps,  to  lift  it  up  ami  circumcize  the  organ  just  below  the  forceps  by  cutting 
through  the  peritoneal  and  on  to  the  muscular  coats.     A  longitudinal  incision, 


Fig.  293.— Showing  the  Enlarged  Inflamed  Appendix  5.5  cm.  long,  1.5  cm.  thick.  Completely  Hidden 
away  by  Newly  formed  Adhesions  Uniting  the  Eledm  to  the  Base  of  the  Cecum  in  the  Ileo- 
cecal  Angle,  this  forming  a  Tent  Completely  Shutting  in  the  Dubase. 

Recurrent  appendicitis.     IV,  ast.  thirty-two,  Feb.  15,  l'J02.     Recovery; 


including  only  these  coats,  is  then  carried  down  to  the  dorsum  of  the  appendix 
as  far  as  it  is  visible,  after  which  the  appendix  can  he  stripped  out  of  its  bed  (see 
Figs.  '-".Hi  and  _'!>7)  by  traction  in  the  direction  of  the  tip,  or  it  can  sometimes 
he  delivered  by  a  straight  pull.  If  it  begins  to  break,  it  must  be  grasped  afresh 
with  the  forceps,  lower  down,  and  the  stripping  process  resumed.  In  this  way 
the  entire  mucosa  with  a  portion  of  the  circular  muscular  coat  is  left  behind 
(Figs.  298  and  299).  There  is  often  no  bleeding  at  all,  and  even  if  there  is,  it 
is  more  easily  controlled  than  when  the  appendix  has  been  dissected  out.     This 


METHOD    OK    STRIPPING    OUT    APPENDIX. 


.",77 


Fig.  294. — H.  A.  Kelly.     I.  Showing  the  Method  of  Stripping  on  the  Mucosa  and  Scbmucosa  in  the 

Case  of  a  Densely  Adherent  Appendix. 


Fig.  295. — H.  A.  Kelly.     The   Incision    is  Continued   a   Short  Distance  down    phb  Appendix,  which  is 

further  Lifted  out  of  its  Serosa  and  Muscular  Coats,  as  shown. 


37 


578 


R]  Mi  i\  \i.   OF  THE    APPENDIX. 


is  a  dangerous  method  if  the  appendix  contains  pus  in  its  distal  portion.  Wal- 
shwi  (Treatise  on  Appendicitis,  1901,  p.  25)  advises  thai  when  i he  appendix 
is  so  adherent  to  importanl  structures  thai  the  whole  of  it  cannot  beremoved, 
it  should  be  divided  near  its  cecal  attachment,  the  proximal  end  closed  in  the 


Fig.  29G. — II    A.  Kki.i.v      The  Remainder  op  THE  Appendix  may 

Tl{A<TK>N. 


■.\    BE    U  IMM'KAWN    IIV   SlMl'I.K 


visual  manner,  and  as  much  of  the  organ  removed  as  safety  will  permit,  either 
by  dissection  or  by  shelling  out  from  the  peritoneal  cavity. 

In  cases  where  the  end  of  the  appendix  enters  a 
small  abscess  cavity  and  is  surrounded  by  adherent  intestines  which 
cannot  be  stripped  off  with  safety,  I  employ  the  following  method:  After  freeing 


REMOVAL    OF    APPENDIX    WHEN    ADHERENT    TO    CECUM. 


579 


the  base  of  the  appendix  from  the  cecum,  I  truce  the  appendix  upward  until 
it  enters  the  abscess  cavity,  as,  for  example,  under  the  ascending  colon,  where 
the  separation  of  adhesions  cannot  be  effected  without  injuring  the  coats  of  the 
bowel.  I  then  pack  off  the  field  of  operation  from  the  surrounding  peritoneum 
on  all  sides,  and  after  dividing  the  appendix  at  its  base  with  a  pair  of  forceps, 
proceed  to  split  it  open  all  the  way  to  the  tip,  using  the  blade  of  a  pair  of  open 
scissors  or  a  grooved  director  as  a  guide.  It  is  thus  possible  to  penetrate  the 
abscess  cavity,  to  open  and  to  cleanse  it,  without  doing  any  damage  to  the  colon. 
In  one  case  of  this  kind,  I  followed  the  cleansing  of  the  cavity  by  drainage,  and 
the  patient  made  an  uninterrupted  recovery.  Whenever  possible  in  these  or 
similar  cases  (see  Figs.  300,  301,  302,  and  303),  the  mucosa  and  submucosa  of 


Inc.  thr.   outer  coats 


Fig.  297.  — II.  A.  Kelly.  When  the  Appendix  hoes  not  Escape  Readily  its  Dorsum  may  be  Incised  down 
to  the  Tip,  when  by  Traction,  as  shown,  the  Inner  Coats  are  Removed  from  their  Muscular  Bed. 
(See  p.  576.) 

the  appendix  should  be  removed  by  dissection  or  by  scraping.  Drainage  should 
always  be  used. 

When  the  appendix  is  lost  in  a  mass  of  adhesions 
surrounding  the  head  of  the  cecum,  and  careful  efforts 
to  release  and  expose  it  arc  unavailing,  the  best  plan,  especially  if  the 
operator  becomes  uncertain  as  to  his  landmarks,  is  to  approach  the  mass  in  an 
entirely  new  direction,  namely,  from  above  and  behind  the  cecum,  as 
recommended  by  W.  H.  Carmalt  (Yale  Med.  Jour.,  Jan.,  1896).  His  case 
was  one  where  an  abscess  had  discharged  into  the  bowel  two  years  previ- 
ously,   and    had    been    followed,    apparently,    by    complete    recovery.      ''The 

•urn,"  he  says,  "presented  itself  directly  under  the  incision,  its  longitudinal 

bands  being  easily  recognizable.  Tracing  these  down  towards  the  head  in 
search  of  the  appendix,  the  cecum  was  found  quite  distorted  in  position,  the 
head  firmly  fixed  and  lost  in  a  mass  of  adhesions  attached  to  the  abdominal 


;>xo 


ukmovvl  or  thk  appendix. 


Fig.  298. — Mixter's  Case.  Showing  thk  Inneb 
I  "usor  the  Appendix,  Including  Mucosa, 
Subhucosa,  ami  a  Few  Fibres  of  thk  (m- 
i  i  i  HUB,  Removed  in  this  Wat. 

'111.-  little  tails  hanging  from  the  appendix  are 

vessels  torn  from  the  outer   coats.       (Natural  size.) 
(See  p.  576.) 


h        ^ 


*4 


Fig.   299. — Blake's  Specimen  of   Long  Appendix 

(24  i  m.i    of  which  the   Proximate    I* n 

has    been    Stripped    oi  i    oi     rrs    Mi  bcuxar 
Bed  in  this  Way. 

a,  a,  a,   are   hernial   protrusions    ->f   'In-    D  i 

through  muscular  hiatus  ;  l>.  !•.  l>.  ;ire  .-similar  hernias 
with  vascular  tit*;  c,  c,  c,  are  vascular  tits  as  shown 
in  preceding  figure.     (See  p.  576.) 


Fig.  29 


REMOVAL    OF   APPENDIX    WHEN    ADHERENT   TO    CEC1  M. 


■>M 


wall  directly  over  the  psoas  muscle.     By  careful  separation  of  these  adhesions 

their  area  was  reduced  from  a  couple  of  inches,  more  or  less,  in  diameter,  to 
about  three-fourths  of  an  inch,  at  which  point  they  were  found  so  dense  that  it 
would  have  been  impossible  to  separate  them  further  without  great  danger  of 
tearing  a  hole  in  the  intestines,  and  as  yet  no  trace  of  the  appendix  was  discover- 
able.    I  therefore  decided  to  approach  the  mass  from  above  and  behind  the 


Fig.  300. — I.  Showing  a  Retb ui     \>  penbo   bo  Buried  in-  a  Bed  of  Adhesions  that  Removal  in  the 

Usual  Manner  is  Fraught  with  Danger  to  the  Coats  of  the  Cecum.      (See  p.  579.) 


cecum,  and  was  obliged  to  enlarge  the  abdominal  incision  an  inch,  so  that  it 
was  about  four  inches  long.  The  appendix,  which  was  quite  buried  in  the  mass, 
was  greatly  enlarged,  being  fully  five  times  the  normal  diameter;  it  was  sharply 
bent  upon  itself,  forming  alternating  contractions  and  dilatations,  and  bound 
together  to  both  intestine  ami  abdominal  wall.  With  some  difficulty  it  was 
isolated  for  about  two-thirds  of  its  distal  extremity,  but  the  proximal  third  was 


582 


UKMoV  \l.   OF  THE    APPENDIX. 


lost  in  the  mass  of  adhesions  already  described  as  binding  down  the  cecum  so 
strongly  to  the  abdominal  wall.  This  was  now  dissected  oft  from  the  wall  so 
that  the  head  of  the  cecum  was  free.  The  appendix  was  cul  off  close  to  the  mass 
after  tying  it  firmly  with  catgut.  The  slump  was  thoroughly  cauterized  with 
pure  carbolic  acid,  the  thick  wad  of  adhesions  now  attached  to  the  cecum  was 

pared  to  one-half  or  less  of  its  thickness,  and  the  surface  cauterized  in  the  same 
way.  The  abdominal  wound  was  then  closed.  The  patient  made  a  g I  recov- 
ery, although  she  was  under  the  anesthetic  somewhat  over  three  hours." 


Fig.  301.  —  IT.  H.  A.  Kelly's  Method  of  Dealing  with  such  an-  Appendix  by  Detaching  thf.  Rase  fihstof 

ALL  AND   (.'LOSING   THE  CECUM.       If  IT   IS   THEN    IMPOSSIBLE   TO    FREE   AN'V    PoHTION    OF   THE    ORGAN    FROM    ITS 

Adhesions  without  Great  Risk  to  the  Coats  of  the  Colon,  it  may  he  Split  Open,  as  shown  in  Don  ED 
Line.     I  See  p    .~>79.) 

Fig.  304  represents  a  buried  retrocecal  appendix  operated 
upon  by  Follis,  who  was  aide  first  to  locate  the  firm  organ  by  palpation  through 
the  cecum,  and  then  to  expose  it  in  its  retro-peritoneal  position  from  the 
cecal  end  by  an  incision  through  the  peritoneum,  as  shown  in  the  lower  figure. 

A  remarkable  and,  I  think,  unique  case  is  that  of  FlNNEY,  shown  in  Fig.  305, 
in  which  aretrocolic  appendix  was  not  only  situate  d 
behind  the  peritoneum,  but  a  c  t  u  a  1 1  y  1  a  y  with  its 
tip    plunged   into  the  substance    of    the    psoas    muscle. 


REMOVAL    OF    APPEXDIX    WHEN    ADHEBENT    TO    OMENTUM. 


583 


W  h  e  n  the  appendix  is  held  do  w  n  1)  y  a  s  li  o  r  t  in  e  s  e  n- 
tery,  or  when  t  li  e  mesentery  is  a  b  s  e  n  t ,  especially  in  cases 
where  the  appendix  extends  high  up  behind  the  cecum,  it  is  best  todetachitat 
the  root,  and  then  extirpate  it  by  pushing  the  colon  gently  to  the  median  line, 
rather  than  by  dragging  on  the  appendix  itself  and  thus  risking  rupture  of  its  ves- 
sels.  A  ease  of  this  kind  in  which  the  appendix  was  tightly  adherent  to  the  cecum 
occurred  in  the  practice  of  Delano  Kircher,  and  was  excised  by  him  without 
ligatures. 

When    the    omentum     is    attached     firmly    to     one    part    of 


Fig.  302. — U   A.  Kelly's  Method.    After  Isolating  the  Appendix  with  Gauze,  its  Exposed  Mucous  Surface 
and  any  Abscess  near  the  Tip  ahe  Carefully  Cleansed  and  Thoroughly  Cauterized.     iS(-e  p,  579.) 


the  appendix,  the  safest  plan  is  to  tie  the  omentum  and  separate  it. 
so  that  the  part  attached  to  the  appendix  is  removed  with  that  organ.  This 
is  particularly  necessary  because  the  omentum,  when  attached  in  this  manner, 
sometimes  encapsulates  a  small  abscess,  or  contains  the  point  of  perforation. 
When  on  opening  the  abdomen,  the  omentum  is  found  adherent  in  the  iliac 
fossa  or  about  the  head  of  the  cecum,  it  should  be  detached  with  the  utmost  care 
a  little  at  a  time  and  under  the  closest  inspection.  When  the  omentum  is  adher- 
ent to  the  appendix  or  wrapped  around  it.  it  is  safe  to  presume  that  there  has 
been  a  perforation  of  the  appendix,  and  that  the  omentum  envelops  an  abscess, 


584 


REMOVAL    OK   THE    APPENDIX. 


which  is  ready  to  distribute  its  contents  over  the  peritoneum  the  moment  the 
barrier  is  removed.    There  are  two  forms  of  omental  adhesions  to  the  appendix, 

namely,  a  knuckle  adhesion  or  an  adhesion  of  the  free  border  directly  against 

the  inflamed  organ ;  and  an  enveloping  of  the  appendix  in  the  border  of  omentum, 

which  is  wrapped  around  the  extremity  of  the  appendix.     The  Omentum  often 

under    these    circumstances    saves    the    life    of   the    patient,    by    grasping 
the  appendix  with  its  infectious  materials,  in   such    a  manner    as    to    prevent 


Fio.  303. — Snows  Such  an  Adherent  Appendix  in  Section,  whose  Walls  are  Fused  with  the  Cecum  and 

Colon, 
The  object  of  the  incision,  cauterization,  and  drainage  is  t<»  leave  the  coat*  of  the  appendix  as  a  protecting 
barrier  to  the  colic  wall  (a).     As  much  of  the  mucosa  ami  inner  wall  should  be  dissected  as  possible.     (See 

p.  ;.7" 


extravasation,  especially  when  the  disease  is  situated  in  the  outer  portion  of  a  free 
appendix. 

When  the  appendix  is  so  concealed  that  it  cannot  readily  lie  identified, 
it  is  important  to  utilize  the  various  landmarks  and  to  investigate  the  cecum 
minutely  on  all  sides  in  order  to  find  its  base,  if  possible,  or  at  least  some  other 
portion.  It  this  is  not  done,  and  the  operator  simply  attempts  to  enucleate  a 
mass  somewhere  in  the  region  of  the  appendix,  lie  may  he  betrayed  into  such 
an  unfortunate  mistake  as  was  mad"  by  X.  P.  Dandridge  (Ann.  Surg.,  1003, 
vol.  38,  p.  367),  which  he  has  reported  with  commendable  frankness  in  order 


Fig.  304. — Follis'  Case  Showing  ink  Appendix  Completely  Con<  baled  under  Adherent  Cecum,  as  is  been 

in  Outline  in  Upper  Figure. 
Palpation  revealed  the  site  of  the  appendix,  which  was  very  hard,  owing  to  a  concretion  in  its  tip.     The  lower 
figure  shims  the  adherent  appendix  as  exposed  by  a  transverse  incision  through  the  peritoneum.     Note  the  man- 
ner in  which  the  vessels  of  the  mesappendix  are  disposed.     G.  A.,  an.  twenty-nine.     Chronic  recurrent  appen- 
dicitis.    Operation  April  9,  1903.     Recovery.     (See  p    582 

585 


586 


REMOV  \l.    OF    I  Hi:    APPKNDIX. 


that  "tlicrs  may  profit  by  his  experience.  In  this  case,  which  was  that  of  a 
man  twenty-six  years  old,  an  incision  was  made  at  the  outer  margin  of  the  rectus, 
and,  as  the  appendix  could  not  be  found,  a  mass  lying  beneath  the  peritoneum, 


Fig.  :i().r>. — Finney's  Casi  in  which  tiif.  Appendix  Lay  Retro-peritonealIiT  and  the  Tip.  op  ho.  Sizi  of  an 
Ai  \ii>\i>.  Containing  a  Concretion,  Lav  Bdrh  d  in  ink.  Si  bsi  ince  oi  phe  Psoas  Mi  b<  le,  is  Shown  in 
the   Right-hand  Figure.     U.   P.   L,  April   18,   1899.     (See  p.  582.) 


to  the  inner  side  of  the  colon  and  above  the  ileocecal  valve,  was  thought  to  lie 
an  exudation  around  it.  This  exudate  was  freed  with  the  finger,  and  a  pulsating 
vessel  of  some  si^e.  which  passed  through  it,  was  ligated.  On  removal,  the  parts 
proved  to  he  a  mass  of  enlarged  glands  about  the  size  of  a  hen's  egg,  which  the 


RETROCECAL    APPENDICITIS.  587 

microscope  showed  were  not  tuberculous.  The  thickened  and  club-shaped  ap- 
pendix was  found  behind  the  cecum  and  removed.  The  wound,  which  was 
completely  closed,  broke  down  after  the  eighth  day,  fecal  matter  escaped, 
and  afterward  about  15  inches  of  small  intestine  and  cecum  sloughed  away. 
This  injury  was  repaired  after  four  intestinal  operations. 

Retrocecal  Appendicitis. — The  fact  that  a  retrocecal  position  of  the  appen- 
dix demands  special  consideration,  and  may  mislead  the  operator  who  is  nut  upon 
his  guard,  was  first  noticed,  to  the  best  of  my  knowledge,  by  C.  B.  Nancrede, 
of  Ann  Arbor,  Michigan  (Med.  News,  INNS,  vol.  52,  p.  570).  Recent  investiga- 
tions show  that  the  retrocecal  position  occurs  more  frequently  than  was  for- 
merly supposed.  Monks  and  Blake  found  that  the  appendix  was  behind  the 
cecum  in  over  17  per  cent,  of  all  cases  (Reports  Bost.  City  Hosp.,  1903);  Byron 
Robinson  found  it  so  situated  in  20  per  cent,  in  men  and  in  35  per  cent,  in 
women  (Ann.  Surg.,  1901,  vol.  33,  p.  407);  while  statistics  from  the  Johns  Hop- 
kins Hospital  give  the  retrocecal  position  as  present  in  20  to  30  per  cent,  of  all 
cases  (Chap.  VI,  p.  127). 

It  often  becomes  necessary,  therefore,  to  treat  cases  of  appendictis  in  which 
the  appendix  must  be  sought  for  behind  the  cecum.  Several  instances  of  this 
kind  which  have  recently  come  under  my  observation  induced  me  to  hope  that  it 
would  be  possible  to  find  in  retrocecal  appendicitis  such  a  characteristic  syndrome 
of  symptoms  as  would  clearly  define  this  interesting  and  important  group  of 
cases  at  the  bedside.  If  we  could,  with  a  fair  degree  of  certainty,  predicate  in  a 
large  percentage  of  cases  that  the  appendix  and  the  abscess  were  to  be  found 
in  a  retrocecal  position,  such  knowledge  would  be  of  material  aid  to  the  surgeon 
in  guiding  his  exploration.  If,  for  example,  he  knew  that  the  appendix  lay 
behind  the  cecum,  he  would  often  seek  to  conduct  the  operation  extra-perito- 
neallv,  lifting  up  the  peritoneum,  much  as  is  done  in  tying  the  common  iliac 
artery;  and  he  would,  in  many  instances,  make  his  external  incision  at  a  point 
higher  up,  above  the  crest  of  the  ilium ;  and  with  the  colon  once  exposed  he  would 
with  greater  precision  seek  for  the  appendix,  which  has  not  infrequently  been 
abandoned  and  recorded  as  "not  found"  in  cases  belonging  to  this  very  group. 

My  investigation  of  this  point  has  covered  the  histories  of  90  patients  in 
whom  the  appendix  occupied  the  retrocecal  position;  40  of  which  were  gathered 
from  general  medical  literature,  and  50  from  the  records  of  the  Johns  Hopkins 
Hospital,  all  of  the  latter,  with  two  exceptions  occurring  in  my  own  clinic, 
being  from  the  service  of  my  colleague,  Prof.  YV.  S.  Halsted. 

In  order  to  determine  any  special  characteristics  which  might  mark  this  group 
the  following  points  were  determined :  (I)  The  seat  of  pain ;  (2)  the  seat  of  swell- 
ing, and  its  form;  (3)  adduction  of  the  right  thigh;  (4)  the  presence  of  blood 
and  mucus  in  the  stools. 

The  pain  was  located  in  the  right  iliac  fossa  in  65  of  the  90  cases.  In  (i  of 
the  40  cases  collected  from  literature  it  was  present  in  the  right  loin,  but  it  was 
not  noted  as  so  found  in  any  of  the  others. 


■VSX  REMOV  \l.   OF  THE    APPENDIX. 

The  scat  of  tlic  swelling  whenever  stated,  was  in  the  righi  iliac  fossa. 
and  in  both  my  own  cases,  as  well  as  in  some  others,  it  is  noted  as  extending 
backward  toward  the  loin.  Ii  is  frequently  noted  that  the  swelling  was  ill 
defined. 

Adduction  of  the  thigh  is  only  noted  in  a  few  cases,  and  the  same  is  to  be 
said  of  blood  and  mucus  in  the  stools,  which  appear  as  a  note  in  the  history 
but  5  times  in  all. 

In  60  out  of  the  (to  cases,  previous  attacks  are  noted  to  have  occurred. 

It  is  manifest  that  no  special  group  of  symptoms  can  be  constructed  from 
these  facts.  I  believe,  however,  that  there  is  a  tendency  on  the  part  of  the  abscess 
to  extend  upward,  behind  the  cecum,  and  out  toward  the  iliac  brim,  forming  an 
elongated  swelling  high  up.  In  cases  where  this  occurs  we  may  reasonably 
expect  that  the  appendix  will  be  found  behind  the  cecum,  and  make  a  corre- 
sponding incision  in  the  loin,  working  back  toward  the  retrocecal  region  in  the 
endeavor  to  expose  the  affected  area. 

The  matter  has  not,  as  yet,  been  borne  specially  in  mind  by  surgeons,  and 
I  venture  to  hope  that  closer  attention  will  reveal  some  differential  points  of 
value,  which  may  enable  us  to  subdivide  this  difficult  subjecl  and  thus  simplify 

the    treatment    of    at    least     one    group    of    obscure    cases.      I     present    here   brief 
historic-  of  the  two  cases  occurring  in  my  own   practice. 

1.  Miss  A.  lb  (J.  II.  II.,  Gyn.  No.  8060,  age  seventeen.)  The  patient  gave 
a  history  of  five  previous  attacks  of  appendicitis,  and  stated  that  she  had  nol 
been  free  from  suffering  since  the  third,  at  which  time  the  pain  became  localized  in 
the  right  iliac  fossa.  There  was  decided  resistance  in  the  region  of  the  caput  ceci 
on  palpation,  and  the  indurated  area  was  cylindrical,  extending  upward  along  the 
outer  border  of  the  rectus  muscle  to  the  umbilical  level.  The  resistant  body,  which 
could  not  be  displaced,  was  palpable  between  the  fingers  and  the  pelvic  brim.  The 
mass  in  the  cecal  region  was  thoughl  to  be  fecal,  since  pressure  caused  gurgling. 
An  incision  in  the  line  of  the  external  oblique  muscle,  rather  high  up  and  awaj 
from  the  anterior  superior  spine,  revealed  a  mass  posterior  to  the  cecum  and  as- 
cending colon,  which  proved  to  be  a  sac  with  thick  necrotic  walls,  containing  the 
appendix  in  its  centre.     Extirpation  was  followed  by  recovery. 

2.  Mrs.  E.  X.  (J.  II.  II..  Gyn.  No.  9009,  age  thirty-nine.)  The  patient  pave 
a  history  of  two  previous  attacks,  the  first  of  them  a  year  previously.  The  second 
one  began  with  severe  pain  in  the  abdomen,  at  first  diffuse,  and  then  localized  in 
the  right  iliac  fossa.  There  was  slight  general  fulness  on  the  right  side  of  the  ab- 
domen, and  distention  of  the  superficial  veins,  with  some  tenderness.  On  palpation, 
an  elongated,  circumscribed  mass,  11  cm.  in  length  and  :\  cm.  in  breadth,  could  be 
made  out ,  filling  the  upper  portion  of  the  righi  iliac  fossa.  An  incision  made  parallel 
to  Poupart's  Iigamenl  disclosed  an  abscess  containing  2  ounces  of  ••laudable"  pus. 
By  pressure  over  the  abdominal  wall  the  cecum  was  delivered  with  its  abscess  walls, 
and  by  tracing  its  longitudinal  bands,  the  base  of  the  appendix  was  located,  behind 
it.  The  tip  of  the  cecum,  which  was  gangrenous,  opened  into  the  abscess.  The 
appendix  was  removed,  and  the  patient  made  a  g 1  recovery. 


DISEASE    IN    NEIGHBORHOOD    OF    APPENDIX.  589 

There  is  a  well-defined  group  of  cases,  where  the  appendix  lies  back  of  the 
cecum  and  the  ascending  colon,  in  which  a  small  pus  cavity  torms 
s  o  in  e  w  h  e  re  n  e  a  r  t  h  e  tip  of  t  h  e  a  p  p  e  n  d  i  x  and  c  o  n  - 
t i n u e s  to  cause  exacerbations  in  the  symptoms  from 
time  to  time.  The  appendix  is  always  embedded  in  a  mass  of 
inflammatory  tissue  and  plastered  into  the  walls  of  the  cecum  so  firmly 
that  it  is  impossible  to  separate  it  without  injury  to  the  larger  bowel.  The 
abscess  may  be  an  old  one,  with  thickened,  inspissated  pus,  or  it  may  con- 
tain a  few  cubic  centimetres  of  pure  pus,  and  sometimes  a  concretion  is  found 
lying  outside  the  appendix. 

Whenever  the  induration  or  area  of  fluctuation  extends  upward  and  backward 
toward  the  loin,  having  an  elongate,  ovoid,  or  a  sausage  shape,  it  is  better  to 
make  the  incision  correspondingly  over  the  iliac  brim,  and  even  to  extend  it  around 
the  side  somewhat  posteriorly.  After  cutting  through  the  skin,  in  a  direction 
from  above  obliquely  downward,  the  oblique  muscles  are  best  separated  by 
a  blunt  dissection  in  the  direction  of  their  fibres  ;  the  transversalis  is  pierced  with 
the  blunt  end  of  an  artery  forceps,  and  the  abscess  cavity  opened.  If  it  is  desir- 
able to  secure  more  room  for  drainage,  the  muscle  fibres  of  the  internal  oblique 
may  then  be  carefully  incised,  avoiding  the  injury  of  any  nerve  trunk.  The 
advantage  of  an  incision  in  this  locality  lies  manifestly  in  it-  dependent  position 
for  drainage,  when  the  patient  lies  recumbent  or  turned  somewhat  to  the  right 
side.  If  the  abscess  is  a  long  or  a  large  one,  a  counter-opening  may  be  made 
below,  over  the  iliac  fossa,  so  as  to  facilitate  the  cleansing  by  through-and- 
through  irrigation. 

Disease  in  the  Neighborhood  of  the  Appendix. — The  surgeon  should  never 
be  contented  to  discover  and  remove  a  diseased  appendix  only;  he  ought  also 
always  to  explore  the  parts  within  reach  in  order  to  discover  any  evidence  of 
further  disease,  hirst,  he  should  investigate  the  condition  of  the  cecum,  for 
sometimes  there  is  an  evident  involvement  of  that  portion  of  its  base  surround- 
ing the  insertion  of  the  appendix,  and  occasionally  isolated  ulcers  may  be  found 
at  some  point  in  the  caput  coli,  when  they  should  be  excised. 

Figs.  306  and  307  illustrate  the  method  of  excision  to  be  used  when  the  dis- 
ease h  located  in  the  neighborhood  of  the  appendix  or  surrounds  the  cecal 
orifice  of  the  appendix,  as  in  a  case  reported  by  C.  Fengee  (Amer.  Jour.  Obst., 
1893.  p.  194). 

The  patient  was  a  man  of  thirty-two.  He  had  had  two  typical  attacks  of  ap- 
pendicitis, the  second  of  which  was  followed,  a  month  later,  by  an  abscess  which 
was  incised,  leaving  a  fistula  in  the  right  lumbar  region  which  was  still  open  when 
he  consulted  Fenger,  a  year  later.  The  patient's  whole  right  side  was  then  occupied 
by  a  board-like  swelling,  covered  with  dilated  veins  in  the  lumbar  region,  while 
below  the  twelfth  rib  there  was  a  fistulous  opening.  This  large  abscess  was  opened 
bv  an  incision  leading  from   Petit's  triangle,  downward  and  forward  toward  the 


5«J0 


REMOVAL    OF   THE     WI'KNDIX. 


cresl  of  the  ilium,  cutting  through  skin,  oblique  muscles,  and  a  layer  of  hard,  white, 
connective  tissue,  a  half  an  inch  t hick.  From  this  cavity  there  opened  a  sinus 
which  was  found  to  run  down  into  the  iliac  fossa,  and  extend  from  there  down- 
ward to  four  inches  below  Poupart's  ligament,  along  the  line  of  the  femoral  vessels. 

In  an  upward  direction  the  sinus  extended  under  the  ribs  and  the  liver,  as  well  as 
backward  four  inches  toward  the  vertebral  column.  These  cavities  were  curetted 
and  the  granulation  lining  removed.  During  irrigation  of  the  upper  cavity  an 
unusually  large  fecal  stone,  an  inch  and  a  quarter  long  and  a  quarter  of  an  inch 
wide,  was  washed  out.  Two  drainage-tubes  were  passed  in  opposite  directions, 
and  the  cavity  filled  with  iodoform  gauze.  A  month  later  a  second  fecal 
stone  was  washed  out,  and  in  another  month  the  cavity  had  closed. 


Tip  adS  to  ileum 
small  abscess  tavity 


I'ii;.  30f>. — Christian  Fencer's  Case  of  Appendix  Densely  Adherent  to  Caput  Coli  and  Ileum. 


Another  group  of  cases  in  which  the  large  bowel  is  more  or  less  involved 
is  that  of  a  tuberculous  process  involving  the  cecum 
(ileocecal  tumor)  in  its  early  stages;  and  in  such  instances,  if  the  attention  of  the 
operator  is  directed  to  the  diseased  appendix  alone,  he  may  amputate  this, 
and  then  have  the  annoyance  of  seeing  a  permanent  fecal  fistula  remain,  while 
the  disease  in  the  iliac  fossa  advances.  Richardson'  CV.  )'.  Med.  Jour.,  inly, 
1901).  in  speaking  of  cases  where  he  has  been  called  on  to  operate  for  permanent 
fistula  following  operation  for  appendicitis,  says:  "In  several  of  these  patients 
it  was  necessary  to  resect  a  large  portion  of  the  cecum,  for  the  tubercular  pro- 


ILEOCECAL    TUMOR. 


591 


cess  had  invaded  all  the  layers,  and  had  caused  extensive  ulceration  of  the  mucous 
membrane." 

Fistula. — Fistula  occurs  in  connection  with  disease  of  the  appendix  under  one 
of  two  conditions,  namely: 

1.  As  a  sequela  to  appendicitis.     These  cases  will  be  considered  in  Chap. 
XXIX. 

2.  As  a  complication  of  chronic  appendicitis.     In  these  cases  the  treatment 


Denuded   area,  on   ileum. 


Fig.  307. — Fencer's  Cask  Showing  ibove  the  Thickened  Tip  and  the  Perforation  near  the  Bask. 

The  middle  figure  shows  the  perforation  and  the  area  of  tissue  excised,  including  both  perforation  and  base 
of  the  appendix.  The  opening  was  closed  by  a  continuous  suture  in  the  mucosa  (x).  a  row  of  I.embert  sutures 
(y)  including  serosa  and  muscularis,  and  over  this  a  serous  suture  burying  the  whole. 


is  concerned  with  the  removal  of  the  appendix  as  well  as  with  the  cure  of  the 
fistula,  and  they  will,  therefore,  he  considered  here. 

In  operations  where  there  is  an  indurated,  suppurating  area,  with  a  fistulous 
opening  on  to  the  exterior,  the  important  question  is  h  o  w  f  a  r  t  o  c  a  r  r  y 
the  operation.  In  other  words:  shall  an  effort  be  made  to  remove 
the  fistulous  tract  and  the  appendix  together;  or  shall  the  treatment,  at  first, 
consist  simply  in  a  free  incision  with  curettage,  and  the  establishment  of  direct 
and  thorough  drainage? 


592  R]  MOVAL   OF  THE    APPENDIX. 

The  excision  of  the  entire  area  with  the  appendix  as  shown  in  Fig.  308  is  the 
ideal  procedure,  but  it  is  not  always  sale.  It  is  best  adapted  to  those  cases  in 
which  the  fistulous  tract  is  well  defined  and  contracted,  leading  directly  into 
the  diseased  appendix.     A  good  illustration  of  this  class  of  cases  is  the  following: 

Miss  K.  (San..  Feb.,  1902.)  Following  an  operation  for  suspension  of  the 
right  kidney  the  patient  had  an  attack  of  inflammation  and  swelling  on  the  right 
side,  extending  mostly  above,  but  also  somewhat  below,  and  toward  the  anterior 

superior  spi >f  the  ilium.     An  incision  was  made  by  her  physician,  in  the  scar 

of  the  renal  suspensory  operation,  and  about  500  CC  of  pus  discharged;  a  counter- 
opening  was  also  made  below-  the  anterior  superior  spine,  and  a  drain  passed  from 
one  opening  to  the  other.  Soon  after  the  drain  was  removed,  the  fistulous  open- 
ings closed  and  the  abscess  reformed,  to  prevent  which  the  openings  were  then 
kept  open  with  coarse  thread.  It  was  at  last  suspected  that  t  he  appendix  was  keep- 
ing up  the  trouble,  and  sixteen  months  after  the  original  operation,  I   made  an 


Old  scar 


Abd. 


;   veTm. 

I  [g     ins. — Case  of  Van  Cott's.     Fistula  rsou  an  Appendix  onto  Surface  of  Abdomen. 
The  operation  consisted  in  excising  Bear  with  ti^ula  in  appendix  en  nmsae. 

incision  i:i  cm.  long  extending  from  one  fistulous  opening  to  the  other,  and  encir- 
cling both.  All  the  muscles  in  the  abdominal  wall  were  cut  through,  the  retro- 
peritoneal tracts  connecting  the  two  orifices  were  dissected  out,  and  numerous 
bleeding  vessels  in  the  dense  muscular  tissue  were  clamped;  at  a  point  about  one- 
third  of  the  way  above  the  fistulous  orifice  a  fistulous  diverticulum  was  found  running 
down  toward  the  external  iliac  vessels,  which  proved  to  be  the  appendix  wrapped 
in  masses  of  cicatricial  tissue  and  lying  completely  extra-peritoneally,  behind  the 
cecum.  It  was  removed  by  drawing  it  out.  and  at  the  same  time  drawing  back 
the  tissues  until  its  base  was  reached,  after  which  this  was  approached  from  the 
under  side  of  the  cecum  by  rotating  the  inner  side  of  the  latter  upward  and  out- 
ward. The  base  of  the  appendix  was  then  clamped  with  fine  forceps  close  to  the 
cecum,  the  appendix  cut  away  at  once,  and  mattress  sutures  applied  over  the  for- 
ceps, a-  close  as  possible  to  the  root  of  the  appendix.  One  of  the  sutures,  which 
was  of  fine  black  silk,  was  drawn  up  ready  to  be  tied,  and  while  this  was  being  done 
the  forceps   was   released  and   withdrawn.     Several    mattress    sutures  completely 


FISTULA    AS    A    COMPLICATION    OF    APPENDICITIS.  593 

closed  the  wound.  The  first  row  of  sutures  were  covered  in  by  others.  There 
was  no  escape  of  bowel  contents  nor  soiling  of  the  wound  at  any  time.  Some  granu- 
lation tissue  was  cut  out  from  the  lower  part  of  the  wound  in  the  iliac  fossa ;  above, 
there  was  an  opening  in  the  peritoneum,  about  6  cm.  in  length,  through  which 
the  normal  omentum  and  part  of  the  colon  were  prolapsed.  The  protruding  parts 
were  cleansed  with  salt  solution  and  returned,  and  the  peritoneal  opening  care- 
fully closed.  The  wound  was  then  secured  with  two  layers  of  catgut  sutures,  one 
set  in  the  internal  oblique  muscle,  which  had  been  cut  directly  across  its  fibres,  the 
other  in  the  external  oblique,  which  had  been  simply  pulled  apart  in  the  line  of  its 
fibres.  An  iodoform  gauze  drain  was  left  in  each  angle  of  the  wound  on  account 
of  the  unavoidable  contamination  with  the  contents  of  the  fistula.  The  patient 
made  a  good  recovery. 

The  important  points  in  this  operation  are: 

1.  The  occurrence  of  two  persistent  fistuUe. 

2.  The  lateness  of  the  operation  after  the  original  attack. 

3.  The  location  of  the  appendix  in  connection  with  the  position  of  the  abscess, 
by  which  the  distinct  clinical  character  of  this  form  of  retro-peritoneal  appen- 
dicitis is  demonstrated. 

4.  The  character  of  the  operation,  which  demanded  a  much  longer  wound 
than  usual,  and  one  much  higher  up. 

5.  The  method  of  separating  the  external  oblique  fibres,  and  of  cutting  the 
internal  fibres. 

0.  The  removal  of  the  appendix  by  pulling  it  out  of  its  bed,  while  stripping 
it  of  its  adhesions  on  all  sides. 

7.  The  amputation  and  removal  of  the  appendix  by  exposing  its  base  from 
above  and  behind  the  cecum,  instead  of  exposing  it  by  the  trans-peritoneal 
route. 

The  following  case  illustrates  the  use  of  both  methods  successively: 

Miss  C.  (J.  H.  H.,  April,  1S9S,  age  twenty.)  "When  six  or  seven  years  old, 
the  patient  had  an  attack  of  pain  in  the  right  side  followed  by  an  abscess  which 
developed  sufficiently  to  be  opened  in  forty-eight  hours.  Some  clays  after  it 
was  opened,  a  pin  was  found  in  the  dressing,  and  the  whole  trouble  attributed  to 
that.  She  had  no  further  attacks  until  sixteen  years  old.  but  after  that  time 
she  had  several,  the  last  one  occurring  a  week  before  her  admission  to  the  hospital. 
In  this  illness  she  had  pain  and  swelling  in  the  right  iliac  fossa,  with  constipation, 
and  some  pain  and  frequency  in  micturition:  there  were  no  chills,  but  probably 
fever;  no  nausea  nor  vomiting.  On  operation  an  abscess  cavity  was  found  be- 
tween the  skin  and  the  fascia  of  the  external  muscles.  There  was  an  opening, 
about  1  cm.  long,  and  2  cm.  broad,  situated  about  3  cm.  above  Poupart's  liga- 
ment. This  opening  was  lengthened  parallel  to  the  ligament  both  above  and 
below.  At  the  bottom  of  the  cavity  the  fascia  of  the  external  oblique  muscle  was 
found  covered  with  necrotic  material.  No  opening  could  be  found  connecting 
this  with  any  other  cavity  below.  The  walls  of  the  cavity  were  scraped,  the  wound 
38 


.")iU  REMOVAL   OF  THE    APPENDIX. 

was  partially  closed  and  the  cavity  packed.  Thepatienl  recovered,  and  aboul  a  year 
later,  in  June,  1899,  an  interval  operation  was  done  for  removal  of  the  appendix. 
On  opening  the  abdominal  cavity  the  appendix  was  found  adherenl  by  its  tip  to 
the  abdominal  wall.  It  was  removed,  the  muscle  being  excised,  and  the  patient 
made  an  uninterrupted  recovery  (see  Chap.  XVI,  p.  370,  big.  223). 

Obliteration  of  the  Lumen  of  the  Appendix. — Bryant  has  reported  a  ease 
(Jour.  Amir.  Med.  Assoc,  Nov.  .'!.  1894)  in  which  there  was  a  mass  below  the 
cecum  extending  toward  the  cavity  of  the  pelvis.  The  extreme  end  of  the  appen- 
dix was  free  tor  about  hall'  an  inch,  while  the  rest  was  buried  in  exudate  and 
could  not  l>e  found.  During  manipulation  the  end  of  the  appendix  was  torn  off, 
and  a  prolie  was  then  passed  in  until  it  met  witli  an  obstruction  due  to  stricture. 
An  incision  was  then  made  up  to  the  stricture,  a  grooved  director  was  introduced 
up  to  the  cecum,  ami  the  rest  of  the  appendix  was  thus  located.  It  was  dilated 
beyond  the  stricture  and  found  to  contain  much  offensive  pus.  The  appendix 
was  tied  off  and  removed,  after  which  the  wound  was  drained  with  iodoform 
gauze.  I.AtTARD,  of  Nice,  on  opening  an  abscess  containing  one  and  a  half 
litres  of  pus,  found  the  appendix  gangrenous  at  its  free  extremity,  and  so  densely 

adherent  to  the  cecum  for  the  rest  of  its  extent  that  it  could  not  lie  detached 
without  great  risk  of  rupturing  the  bowel.  The  ragged  edges  of  the  wound 
in  the  appendix  were  trimmed  off  smoothly  and  the  opening  was  then  united 
by  four  catgut  sutures  to  the  inner  angle  of  the  abdominal  wound,  and  protected 
by  a  narrow  iodoform  gauze  drain.  The  large  abscess  cavity  was  stuffed  with 
gauze.  In  two  weeks  the  canal  of  tin'  appendix  was  wholly  obliterated  and 
in  three  weeks  the  entire  area  was  cicatrized. 


MECKEL'S   DIVERTICULUM. 

I  'iverticula  of  the  intestine  are  to  he  divided  into  two  classes,  false  and 
true. 

The  false  or  distention  diverticula  are  found  anywhere  in  the  alimentary 
canal,  at  the  mesenteric  border,  at  the  sides,  or  at  the  free  border.  They  are 
round  and  globular,  with  a  somewhat  contracted  base,  and  their  size  varies 
from  that  of  a  pea  to  an  apple,  or  they  may  be  even  larger.  The  individual  coats 
of  the  intestine  are  not  all  continuous  over  these  false  diverticula,  for  on 
dissection  the  fibres  of  the  muscular  coats  are  found  to  he  either  much 
thinned  out,  or  pushed  aside  altogether.  These  diverticula  are  therefore 
hernial  protrusions  of  the  inner  coats  through  the  muscle,  ami  there  may  be 
a  great   number  of  them  on  the  intestine  of  any  one  individual. 

The  true  diverticulum,  or  Meckel's  diverticulum  Uei,  represents  the  most 
frequent  anomaly  of  the  alimentary  canal,  occurring,  according  to  various  statis- 
tics, in  from  0.5  to  L>  per  cent,  of  all  bodies.  It  is  found  within  a  definite  area 
of  the  ileum,  i.e.,  at  a  distance  of  30  to  290  cm.  from  the  ileocecal  valve,  the 
most  frequent  measurement- in  the  adult  being  100  cm.,  in  the  newborn  child 


MECKEL  S    mVEUTKTU'M. 


:»'.».-) 


about  30  cm.  The  diverticulum  may,  however,  in  rare  instances  be  found 
outside  the  classic  region,  either  high  up  (jejunum,  duodenum)  or  far  down 
(cecum,  colon),  according  to  whether  the  upper  or  lower  limb  of  the  primitive 
intestinal  loop  has  undergone  excessive  development.  It  is  always  single  and 
all  the  coats  of  the  intestine  participate  in  its  formation.  Its  shape  is  cylin- 
drical, or  conical,  or  it  may  balloon  at  the  extremity. 

Embryology  of  Meckel's  Diverticulum. — In  the  very  young  embryo  the 
short  and  straight  intestinal  tube  is  still  in  open  communication  with  the  yolk- 
sac,  which  is  situated  directly  in  front  of  it.  As  the  structures  forming  the  body 
wall  grow  from  the  sides  toward  the  front,  they  gradually  narrow  down  the 


<-e    - 


Fig.  309. — Type  I.    Diagram  of  the  most  Primi- 
tive Form  of  Meckel's  Diverticulum,  Resem- 
bling the  Original  Vitelline  Duct. 
It  appears  as  a  short   canal  which  connects  the 
ileum  with  a  ventral  fissure,  the  extent  of  which  may 
be  considerable.     The  distal  ileum  is  insufficiently  de- 
veloped, the  anus  being  either  constricted  or  occluded, 
and  the  intestinal  contents  pass  through  the  fissure. 
The  canal  is  accompanied  by  the  remains  of  the  om- 
phalo-mesenteric  vessels. 


Fig.  310. — Type  II.  Diagram  of  a  More  Advanced 
Form  of  the  Diverth  ili  m. 
The  fissure  persists,  but  is  narrower,  the  canal 
longer  and  more  slender,  and,  owing  to  an  intact  anal 
orifice,  the  intestinal  contents  pass  in  the  usual  man- 
ner. The  omphalo-mesenteric  vessels  accompany 
the  canal. 


communicating  portion  between  the  intestinal  tube  ami  yolk-sac  until  it  is  but 
a  narrow  channel.  This  is  the  vitello-intestinal  or  o  m  p  h  a  1  o  - 
mesenteric  duct,  which  normally  becomes  obliterated  ami  absorbed  as 
soon  as  the  body  wall  of  the  embryo  is  closed.  If  it  fails  to  disappear,  it  may 
persist  in  the  adult  as  Meckel's  diverticulum,  of  which  we  distinguish  four 
different  types.  These  represent,  with  tolerable  exactness,  the  stages 
of  embryological  changes  through  which  this  peculiar  structure  has  to  pass. 

Type  I  . — If  the  arrest  in  development  has  taken  place  before  the  closure 
of  the  opening  of  the  gut  in  the  yolk-sac  lias  occurred,  we  find  a  broad  fissure 
at  the  umbilicus,  through  which  fecal  matter  is  discharged.     Associated  with 


596 


HK.MOVAL    OF   THE    APPENDIX. 


this  condition  is  generally  found  another  anomaly,  dating  back  to  the  same 
embryonic  stage,  namely,  constricted  or  occluded  anus  (see  Fig.  309). 

Type  11. — This  is  a  somewhat  more  advanced  condition,  in  which  tho 
fissure  is  smaller,  the  canal  Longer,  and  owing  to  an  intact  anal  orifice,  the  in- 
testinal contents  pass  in  the  usual  manner.  This  type  may  lie  produced,  ii'  at 
the  time  of  birth,  a  diverticulum  still  extended  part  of  the  way  into  the  cord  and 
became  tied  off  with  it,  an  ulcerative  process  developing  in  the  diverticulum  and 
leading  to  the  formation  of  an  umbilical  fecal  fistula  (see  Fig.  310). 

Ty  pe    III  . — This  is  a  still  further  advanced  stage.     The  ventral  fissure 


L 


Fio.  all.—  Type  III.  Diagram  of  a  Stili. FURTHER  Aovanci  D 
Form  <>f  Diverticulum. 
The  ventral  fissure  is  closed  and  the  distal  portion  <>f  the 
canal  baa  become  i  ransfonned  into  a  fibrous  cord,  which  may  or 
may  not  contain  remains  of  the  omphalo-mesenteric  vessels.  The 
proximal  portion  has  retained  ite  lumen  and  appears  as  a  sac  at- 
tached to  the  free  border  of  the  ileum. 


Fig.  312.— Type  IV.— The  Usual  Form 
of  Meckel's  Dn  eh  i  u  i  li  h. 
The  proximal  portion  <>f  the  original 
vitelline  duct  persists,  but  having  ktomc 
closed  at  its  end  and  detached  from  the 
umbilical  region,  it  appears  as  a  pouch 
hanging  free  from  tin-  convex  border  <>f 
the  ileum.  The  omphalo-mesenteric  ves- 
sels run  up  t'»  its  t  ij». 


is  now  closed:  tho  vitelline  duct  persists  only  in  its  proximal  or  ileal  portion, 
forming  a  diverticulum  of  various  length,  while  its  distal  or  umbilical  portion 
has  become  obliterated  and  transformed  into  a  fibrous  cord,  which  acts  as  a 
suspensory  ligament  for  the  diverticulum  (sec  Fig.  311). 

T  y  p  e  IV  . — This  is  the  form  most  frequently  met  with,  and  is  that  which 
is  most  apt  to  resemble  a  vermiform  appendix.  Here  the  ventral  or  umbilical 
portion  of  the  duct  has  become  absorbed  and  the  ileal  portion  or  diverticulum 
projects  from  the  free  border  of  the  ileum  (see  Fig.  312). 

The  lengt  h  of  Meckel's  diverticulum  varies  from  1  to  20  en...  2.5  cm. 
being  the  most  frequent  measurement. 


MF.t'KEL  S    DIYERTK'll.l  M. 


597 


The  \v  idth  may  be  that  of  the  ileum;  more  often,  however,  it  is  slightly 
less;  it  is  occasionally  very  narrow,  resembling  a  vermiform  appendix  (Fig. 
313).  Again,  many  eases  have  been  noted  in  which  a  diverticulum  was  found 
two  or  three  times  as  wide  as  the  adjacent  ileum. 

The  diverticulum  is  generally  attach  e  d  to  the  free  margin  of  the  ileum, 
i.  e.,  opposite  the  mesenteric  border,  in  which  case,  however,  its  axis  frequently 
points  toward  either  one  side  or  the  other.  It  may.  however,  also  come 
off  at  the  'sides  or  even  near  the  mesentery.     Orth  (Lehrb.  d.  spedellen  Path. 


Fig.  313. — Aw    Unusually  Narrow  Meckel's  Diverticvlvm,    which  might    easily    be    Mistaken    for  an 

Appendix. 
The  resemblance  is  still  more  marked  if  viewed  upside  down.  Careful  examinatii  n  of  its  mode  of  attach- 
ment and  recognition  of  the  fact  that  it  arises  from  the  ileum,  will  at  once  determine  the  true  character  of  the 
structure.  Tor  a  distance  of  2  cm.  the  diverticulum  is  adherent  to  the  ileum,  and  the  resulting  acute  angle  be- 
tween the  two  gives  rise  to  the  existence  of  a  semilunar  valvular  fold  at  the  junction,  which,  however,  does  not 
suffice  t"  prevent  free  communication  between  ileum  and  diverticulum.  The  diverticulum  has  a  well-developed 
mesenteriolum  arising  from  the  mesentery,  in  which  pass  the  omphalo-mesenteric  vessels  supplying  the  organ. 
Specimen  from  the  pathological  collection  of  the  Johns  Hopkins  Hospital,  506.      (Natural  size.) 


Anat.,  Bd.  1,  p.  764)  states  that  it  may  even  be  found  extending  between  the 
loaves  of  the  ileal  mesentery;  but  it  seems  more  likely  that  he  has  referred 
to  a  false  or  distention  diverticulum.  If  attached  to  the  free  border  the  passage 
from  one  to  the  other  is,  as  a  rule,  uninterrupted  by  any  valvular  structure. 
Not  infrequently,  however,  the  diverticulum  is  found  leaning  toward  the  ileum 
in  a  distal  direction  (Fig.  314).  The  resulting  acute  angle  between  ileum  and 
diverticulum  gives  rise  to  the  formation  of  a  semilunar  valvular  fold  at  the 
junction,  similar  in   character   to  the  semilunar  fold   at    the   ceco-appendical 


598 


KI'.MOV  \l.   OF   THE    APPENDIX. 


junction.  The  diverticulum  may  be  closely  adherenl  to  the  ileum  for  a 
variable  distance,  in  which  case  the  semilunar  fold  is  still  more  pronounced 
Fig,  313).  Meckel  ("Ueber  die  Divertikel  am  Darmkanal,"  Arch.  /.  </. 
Physiol.,  Halle,  1809,  Bd.  9,  p.  121)  though*  thai  this  narrowing  and  the 
presence  of  the  valve  signified  a  tendency  on  the  part  of  the  ileum  to  effecl 
a  normal  closure  at  this  point.  If  the  fold  projects  from  both  the  distal  and 
the  proximal  margin  of  the  orifice,  this  assumption  is  not  without  ground,  ami 
there  are  even   instances  where   the  opening  was   completely  occluded    (ORTH, 


leu*"    and 
cliv*rt»t  w 


Hernial  protru*,on& 

1  ....     i 


Omphalo  -  meofnff'f 
ves^f Is- 


,  f ,,  , 


' 


Fig.  314. — A  Meckel's   Diverticulum   Ilei  with  Several  Small  Distention   Diverticula  at  its  distal 

Portion. 

The  diverticulum  is  lituated  at  :i  point  1",  tin.  fiom  the  ileocecal  valve  ami  attached  to  the  free  horder  of 
the  ileum,  pointing,  however,  slightl}  toward  the  under  surface  of  the  intestine.  The  omphalo-mesenteric  vessels 
exist  only  on  t  In-  under  si,[e  (the  embryonic  left  side),  whence  thej  semi  their  hem  dies  around  the  si  i  net  tire.  A 
triangular,  transparent,  non-vascular,  serous  fold  tuns  in  the  distal  acute  angle  between  ileum  and  diverticulum. 
Observed  June  •>.   1904.     (Natural  size.) 


/'»•.  cit.).      If  seen  only  on  the  side  toward  which  the  diverticulum  leans,  it 
should    lie   regarded    as   of  merely  mechanical   origin. 

Tin'  t  i  p  of  the  diverticulum  is  a  subject  of  interest,  in  so  far  as  the  muscular 
coats  are  here  apt  to  leave  gaps  through  which  the  inner  coats  may  protrude. 
These  hernial  formations  vary  from  the  size  of  a  pea  to  that  of  a  walnut.  They 
are  identical  in  character  with  the  above-described  distention  diverticula  found 
at  any  point  of  the  alimentary  canal.  We  thus  have  a  true  .Meckel's  diverticulum 
with  false  diverticula  at  its  cupola  (Fig.  314).  Meckel  (Inc.  cit.)  has  described 
this  peculiarity  and  advanced  the  opinion  that  in  the  development  of  the  diver- 


Meckel's  diverticulum.  599 

ticulum  the  same  energy  is  not  expended  as  in  the  development  of  the  intestine. 
The  entire  process  should  disappear,  and  it  is  not  surprising  that  fortius  reason 
the  remaining  portion,  on  account  of  less  firm  texture,  should  frequently  show 
traces  of  insufficient  development,  more  pronounced  in  the  last  and  weakest 
spot — the  tip. 

The  muscular  layers  of  the  diverticulum  are  similar  to  those  of  the 
ileum;  viz.,  an  inner  circular  and  an  outer  longitudinal.  The  latter,  however, 
is  very  delicate  in  some  specimens,  and  may,  in  places,  lie  wanting.  The 
mucosa  is  also  identical  in  character  with  that  of  the  ileum,  and  (  )sler  (Ann. 
Aunt,  and  Surg.,  1881,  vol.  4,  p.  202)  mentions  a  case  in  which  a  Peyer's 
patch  was  found  in  a  diverticulum. 

The  blood  s  u  p  p  1  y  is  of  sufficient  interest  to  merit  a  brief  description. 
The  diverticulum  is  supplied  by  the  remains  of  the  vitelline  or  omphalomesen- 
teric vessels.  These  belong  to  the  first  circulation  of  the  embryo,  and  through 
them  the  blood  of  the  vascular  area  inclosing  the  yolk-sac  is  carried  info  the 
two  primitive  aortas  of  the  embryo.  Veins  accompany  these  arteries,  which 
are  at  first  multiple,  but  when  the  intestinal  canal  is  formed  they  are  reduced 
to  two,  one  passing  on  either  side  of  the  intestinal  tube.  "When  the  intestine 
bends  away  from  the  now  single  aorta,  to  form  its  first  loop,  the  primitive  mesen- 
tery makes  its  appearance  and  the  omphalo-mesenteric  arteries  unite  to  form 
one  single  vessel,  which  arises  from  the  aorta  and  passes  inside  the  newly  formed 
mesentery  to  the  most  ventral  portion,  where  it  divides  into  two  branches 
which  pass  right  and  left  around  the  intestine  and  then  into  what  remains  of 
the  vitelline  duct  and  yolk-sac.  The  omphalo-mesenteric  artery  changes  in 
later  stages  into  the  main  trunk  of  the  superior  mesenteric  artery,  and  the 
portion  of  the  intestine  in  the  adult  toward  which  this  artery  points  is  the 
region  where  the  vitelline  duct  has  been,  and  where  we  have  to  look  for  a 
Meckel's  diverticulum. 

Even  if  the  diverticulum  disappears,  the  omphalo-mesenteric  artery  may 
persist  and  run  in  a  connective-tissue  strand  up  to  the  umbilicus.  This  was 
the  case  in  a  man,  fifty-four  years  of  age,  mentioned  by  Huntington  (Anat- 
omy of  the  Peritoneum  and  Abdomen,  1903).  The  strand  containing  the  om- 
phalo-mesenteric artery  may  arise  from  the  ileum  or  from  the  mesentery,  and 
its  presence  among  the  intestines  is  undoubtedly  an  element  of  danger. 
According  to  Orth  (loc.  fit.),  this  fibrous  Viand  may  exist  between  the  ileum 
and  umbilicus  without  the  presence  of  a  diverticulum,  or  a  diverticulum  may 
be  found  adherent,  with  or  without  a  band,  not  to  the  umbilicus,  but  to 
another  portion  of  the  parietal  or  visceral  peritoneum;  and  finally  a  band 
may  arise  from  the  umbilicus  and  be  attached,  not  to  the  intestine,  but  else- 
where. 

The  diverticulum  may  be  supplied  by  two  persistent  branches  of  the  omphalo- 
mesenteric artery,  or  there  may  be  only  one,  the  other  having  become  atrophied. 
From  the  material  at  my  disposal,  it  appears  that  the  right  (embryonic  term) 


(i()ll 


i;i   MOVAI.    OF    TIIF,    APPENDIX. 


or   upper   branch    is   more    apt  to  atrophy.     In  Fig.  314  the  diverticulum  is 

supplied  by  the  left  branch  (embryonic  term),  i.  e.,  the  one  running  around 
the  under  surface  of  the  ileum.  It  courses  along  the  side  of  the  diverticulum 
toward  the  tip.  and  gives  off  branches  to  right  and  left. 

In  case  there  are  two  omphalomesenteric  arteries  (Fig.  315)  they  ascend 
one  on  either  side,  but  not  exactly  opposite  one  another.  The  branches  given 
off  form  broad  anastomoses  with  those  coming  from  the  other  side.  When 
viewed  from  the  side,  we  see  three  or  four  superimposed  vascular  arches  passing 


'"  '"oenter.olun, 


Fig.  31o.—  A  Largi    Meckel's  Diverticulum  7<i  cm.  from  the  Valve. 

It  is  supplied  by  two  omphalomesenteric  arteries,  one  of  which  has  given  rise  to  the  formation  of  a  mesen- 
teriolum  on  the  under  surface  (embryonic  left),  while  the  other  passe-  in  close  contacl  with  the  ileum  ami  diver- 
ticulum along  1  lie  upper  sin  face  (embryonic  right).  Broad  anastonii  1  ihl'  branches  pass  between  the  two.  Au- 
topsy,  March   17,    1S99.      (Two-t birds  natural  size.) 


in  intervals  of  1  to  2  cm.  from  the  right  to  the  left  omphalo-mesenteric  vessel. 
They  become  shorter  as  they  approach  the  tip.  All  arteries  are  accompanied 
by  veins. 

An  important  feature  of  the  vascularization  is  the  occasional  presence  of  a 
m  e  s  e  n  t  e  r  i  o  1  u  m  which  contains  the  omphalo-mesenteric  vessels.  While 
in  some  instances  in  which  the  diverticulum  is  short  and  attached  to  a  portion 
of  the  ileum  equally  far  away  from  the  mesenteric  border,  the  vessels  hug  the 
ileum  closely  without  lifting  up  any  serous  fold  ;  in  other  instances,  in  which 
the  diverticulum  is  long,  or  in  which  it  arises  more  from  the  upper  or  lower  side 


Meckel's  diverticulum.  GUI 

of  the  ileum,  the  vessels  are  very  apt  to  lift  up  a  serous  fold  of  various  size, 
which  may  contain  a  considerable  amount  of  fat  and  resemble  in  every  way 
the  mesenteriolum  of  the  appendix.  It  extends  from  the  mesentery  near  the 
ileal  border  up  to  the  tip  of  the  diverticulum,  but  may  also  be  shorter.  Some- 
times it  forms  a  little  fatty  protuberance  at  the  tip.  It  is  evident  that  the 
development  of  such  a  structure  is  purely  mechanical,  resulting  from  the  oblique 
position  of  a  contracting  and  expanding  tube  in  which  the  vessels  were  sub- 
jected to  tension  and  lifted  up  a  triangular  peritoneal  reduplication.  Excessive 
distention  of  such  a  specimen  shows  clearly  that  tension  of  the  vessels  produced 
the  mesenteriolum  (Fig.  315).  If  there  are  two  omphalo-mesenteric  arteries, 
only  one  lifts  up  a  mesenteriolum,  i.  e.,  the  one  on  the  concave  surface,  while 
the  other  courses  along  the  convex  side  of  the  ileum  and  diverticulum,  accom- 
panied by  a  varying  amount  of  fat. 

A  diverticulum  may  also  possess  an  on- vascular  serous  fold, 
which  passes  in  the  acute  angle  between  the  ileum  and  diverticulum.  It 
is  triangular  in  form  and  closely  resembles  the  ileocecal  fold  (Fig.  314,  p. 
598). 

It  is  worthy  of  note  that  Meckel's  diverticulum  is  frequently  associated 
with  other  anomalies ;  such  as,  harelip,  cleft  palate,  insuffi- 
cient development  of  the  bones  of  the  skull,  spina 
bifida,  congenital  deficiency  of  septum  of  the  heart, 
ventral  fissure,  double  uterus,  horseshoe  kidney, 
double  bladder,  exstrophy  of  bladder,  atresia  of 
anus,  club-foot,  supernumerary  digits,  transposi- 
tion  of    the    viscera,    double    and    triple    monsters. 

Another  interesting  feature  is  that  a  Meckel's  diverticulum  has  been  found 
in  several  children  of  the  same  parents,  Jaeger  (Dtsch.  Arch.  j.  Physiol,  Halle, 
1817,  Bd.  3,  p.  539)  reporting  two  cases  of  infants  with  this  anomaly,  and 
Riefkohl  (Berl.  Id.  Wochenschr.,  1S74,  Bd.  11,  p.  249)  three,  one  of  the  three, 
however,  being  doubtful. 

Pathology. — The  presence  of  a  diverticulum  ma}-  give  rise  to  a  number 
of  pathological  conditions.  The  fibrous  band  passing  from  the  tip  of  the  sac 
to  the  abdominal  wall  or  to  any  part  of  the  viscera  may  form  a  ring  in  which 
the  bowel  can  become  strangulated.  The  existence  of  a  valvular  structure  at 
the  junction  between  the  ileum  and  the  diverticulum  may  cause  a  retention  of 
the  secretion  of  the  mucous  membrane  of  the  diverticulum  and  give  rise  to  the 
formation  of  a  cystic  dilatation,  a  so-called  entero-cystoma. 

Foreign  bodies,  such  as  cherry-stones,  peas,  orange  pips  (Osler,  loc.  cit.), 
may  enter  a  diverticulum  and  bring  about  inflammation  and  ulceration;  while 
fecal  concretions  have  not  to  my  knowledge  been  reported. 

Typhoid  ulceration  in  a  Peyer's  patch  situated  in  a  diverticulum,  with 
perforation,  has  been  observed  by  Galton  (Trans.  Path.  Soc.  Lond.,  vol. 
23). 


(id.'  REMOVAL   OF   THE    APPENDIX. 

A  diverticulum  may  enter  an  inguinal  hernia  and  become  adherent  with 
subsequent  inflammation  and  perforation. 

Finally,  it  may,  on  becoming  inflamed,  simulate  in  all  respects  an  attack 
of  appendicitis. 

S  y  in  p  t  o  in  s  . — The  symptoms  of  a  diverticulitis  are  in  all  respects  sim- 
ilar to  those  of  an  appendicitis,  except  that  the  pain  may  he  situated  somewhat 
higher  up  than  is  usual  in  inflammation  of  the  appendix, as  was  noticed  in  two 
cases,  by  Finney.  A  good  illustration  of  such  a  case  has  been  furnished  me  by 
C.  OviATT,  of  Oshkosh,  Wis.,  in  a   personal  communication. 

The  patient,  who  was  a  man  thirty-six  years  old.  had  had  three  well-defined 
attacks  of  appendicitis  within  a  year.  The  last  attack  differed  from  the  others  m 
ilie  fact  that  there  were  t  wo  distinct  foci  of  pain  and  tenderness, 
one  slightly  b  el  o  w  M  c  B  u  r  n  e  y  '  s  point,  the  other  about  1  '_'  c  m  . 
above  it  .  nearly  on  a  line  with  the  umbilicus  and  at  the  outer  border  of  the  rectus 
muscle.  He  was  admitted  to  the  hospital  when  recovering  from  the  third  attack. 
At  this  time  the  upper  focus  was  more  sensitive  to  touch  than  the  lower.  The 
ordinary  incision  along  the  border  of  the  rectus  was  made,  and  an  appendix  which 
contained  a  good-sized  fecal  stone  removed.  Upon  extending  the  wound  to  the 
upper  focus  of  pain,  a  mass  of  adhesions  was  encountered,  which,  when  freed,  showed 
a  .Meckel's  diverticulum  S  cm.  in  length,  and  about  two-thirds  the  size  <>i  the  ileum. 
It  had  evidently  been  hut  recently  in  a  state  of  active  inflammation  similar  to 
that  in  the  appendix.  The  diverticulum  was  removed  close  to  the  ileum,  and  the 
wound  closed  with  the  Czerny-Lembert  sutures;  the  abdominal  wound  was  closed 
without  drainage.     The  patient  made  a  good  recovery. 

Treatment  . — The  operation  for  diverticulitis  consists  in  the  detachment 
and  isolation  of  the  diverticulum,  extreme  care  being  taken  not  to  rupture 
its  tender  coats.  The  mesentery,  if  present,  is  ligated,  and  the  diverticulum 
also  is  ligated  near  the  ileum,  the  bowel  wall  being  kept  well  elevated,  and 
pinched  together  to  prevent  any  escape  of  its  contents.  The  wound  is  then 
closed  with  mattress  sutures,  which  are  again  turned  in  with  sero-serous 
sutures.  If  a  large  diverticulum  is  caught  in  a  hernia  and  strangulated,  it 
may  be  necessary  to  resect  the  bowel  in  part,  or  even  across  its  entire  lumen. 


CHAPTER   XXVI. 

ABSCESS   IN   THE   NEIGHBORHOOD   OF   THE  APPENDIX,    OR   SUP- 
PURATIVE PERI-APPENDICITIS. 

REMOVAL    OF    THE    APPENDIX    IN    SUPPURATIVE    CASES.     TREATMENT    OF  AB- 
SCESS.    TREATMENT  OF  ABSCESS  IN  SPECIAL  CASES.     PELVIC 
APPENDICAL  ABSCESS. 

The  term  suppurative  peri-appendicitis,  introduced  by 
Terrier,  includes  all  cases  in  which  the  suppuration  is  localized  in  the  neigh- 
borhood of  the  appendix,  or,  in  other  words,  in  which  there  is  an  i  1  i  a  c  , 
lumbar,  pelvic,  inter-intestinal,  sub-umbilical,  or 
retrocecal     abscess. 

The  location  of  an  abscess  directly  connected  with  the  appendix  varies 
according  to:  the  position  and  the  length  of  the  appendix;  the  situation  of 
the  infected  area,  whether  in  the  middle,  the  base,  or  the  tip;  the  presence  of 
abnormalities  in  the  position  of  the  cecum,  or  of  the  appendix.  An  appendix 
of  average  length,  for  example,  may  lie  in  the  iliac  fossa,  or  it  may  hang  over 
the  pelvic  brim  into  the  pelvis,  or  it  may  lie  under  the  ileum,  or  behind  or  in 
front  of  the  cecum  to  the  inside  (Fig.  318,  p.  606)  or  outside,  or,  finally,  it  may 
lie  underneath  the  cecum  (Figs.  316  and  317,  pp.  604  and  605). 

In  some  cases  the  presence  of  a  pocket  or  a  peritoneal  diverticulum  will 
determine  the  location  of  an  abscess  and  limit  its  extent,  as  in  Fig.  203  (see  p. 
326),  where  an  acute  process  in  the  tip  might  lie  shut  off  by  an  agglutination  of 
the  peritoneal  surface  at  the  mouth  of  the  pocket.  In  some  extraordinary  in- 
stances the  appendix  may  be  completely  concealed  under  one  or  more  layers  of 
peritoneal  folds  with  more  or  less  valve-like  openings  (see  Fig.  319,  p.  607),  in 
which  case  great  anatomic  advantages  exist  for  the  limitation  of  a  spread  of 
infection. 

Mikulicz  has  drawn  especial  attention  to  the  natural  barriers  in  the  ab- 
domen (see  Fig.  320,  p.  608),  which  tend  to  limit,  and  also  to  determine  the  direc- 
tion of  the  spread  of  any  infectious  materials.  The  abdomen,  as  he  has  shown, 
may  be  divided  into  a  supra-omental  and  an  infra-omental  space;  the  supra- 
omental  space  being  subdivided  into  a  subphrenic  and  an  infra-hepatic.  The 
diaphragmatic  area  is  again  subdivided  into  right  and  left  areas  by  the  hepatic 
ligament.  The  space  below  the  transverse  colon  and  the  omentum  is  sub- 
divided by  the  mesentery  of  the  ileum,  which  follows  a  generally  oblique 
direction  from  above  on  the  left,  down  into  the  right  iliac  fossa.  The  pelvic 
cavity  constitutes  the  most  important  subdivision  of  the  lower  area.      It  will  at 

603 


C.04 


ABSCESS    IN    NEIGHBORHOOD    OF    APPENDIX. 


Fig.  316. — A  Composite  Picture  Showing  the  Vauious  Positions  in  which  an  Abscess  may  be  Found,   in 

the  Pelvis,  behind  or  in  front  of  the  Ileum,  or  behind  the  Colon-  ok  the  CECUM.     (See  p.  603.) 

The  location  of  the  abscess,  as  a  rule,  is  determined  by  the  position  of  the  appendix. 


LOCATION   OF   ABSCESSES    IN   THE    ILEOCECAL    REGION. 


605 


relro- colic 


iliac  fossa7  ^ 

Fig.  317. — The  Location  of  Various  Small  Abscesses  in  the  Ileocolic  Region.     (See  p.  603.) 


600 


ABSCESS     IX     NKKIimoKIlOOD    OF    APPENDIX. 


Fig.  318. — Showing  an  Appendix  Coiled  on  Itself  in  Spiral  Form  Below  and  in  Front  of  the  Ileocecal 

Jim  in  in. 

The  ileum  is  shown  lifted  up,  bo  as  to  expose  the  proximal  portion  of  the  appendix.     Hie  appendix  wai  '' 
down  by  numerous  adhesions,  passing  in  every  direction,  immobilizing  the  individual  coils  of  the  organ.     Tin-  tip, 
however,  was  free  and  pointed  directly  forward.     The  whole  organ  was  intensely  Inflamed,    o  much    o  as  to  make 
it  impossible  to  recognize  the  different  coils  until  the  adhesions  hud  been  partially  severed  and  removed.     The 

extraordinary  spiral  form  of  the  appendix  resemble.-,  in  a  remarkable  manner,  a  rattlesnake  coiled  and  ready  to 
spring. 


APPENDIX    BURIED    UNDER    PERITONEAL    FOLDS. 


607 


Fig.  319. — \Y.  W.  Russell's  Case  Showing  the  Appendix  Buried  under  Two  Layers  of  Peritoneal  Folds 

Forming  Two  Pockets.      iSee  p.  603.) 

The  appendix  lay  flexed  on  it  -elf  in  the  innermost  pocket,  as  shown  in  the  upper  right-hand  figure.     Gyn.  clinic. 

October  S,  1903.     Note  that  the  ileocecal  fold  is  continuous  with  the  broad  ligament. 


608 


ABSCESS    IN    NEIGHBORHOOD    OF    APPENDIX. 


■wbphpeni'r  portion 


Infra  - 

omental 
space 


Supra  - 

omental 
space 


Fig.  320. — Mikulicz's  Barriers  to  the  Spread  of  Infection,  Aiding  in*  the  Localization  op  Inflammatory 

Products.     (See  p.  603.) 


ABDOMINAL    FOSS.li. 


609 


Fig.  321. — Abdomen  Showing  Three  Major  Foss.t.   Right  and  Left  Abdominal,   and  Pelvic. 

The  abdominal  fossae  are  subdivided  into  renal  and  iliac.     In  these  fossa-  fluids  are  prone  to  accumulate  with  the 

patient  in  recumbent  position.     (See  p.  601.) 


39 


610 


ABDOMINAL    FOSS.*. 


611 


once  be  seen  that  an  abscess  starting  below  the  mesentery  will  be  prone 
to  enter  the  pelvis  and  extend  into  the  opposite  iliac  fossa,  while  an  abscess  on 
the  outer  side  of  the  colon  may  readily  extend  upward  into  the  region  of 
the  liver. 


rentoi  cav      Ileocecal  valve 


PelV: 


fascia  ~  r'%7 


f 


]/ 


"     04-       r 

Fig.  323. — Horizontal  Section  just  above  the  Insertion'  of  the  Appendix,  Showing  the  Relations  of 
the  Appendix  and  the  Tissues  of  the  Mesappendix  to  the  Fasci  b  lnd  Muscles  of  the  Posterior 
Abdominal  Wall. 

This  figure  also  demonstrates  the  method  of  approaching  an  abscess  about  the  appendix  by  an  extra-peri- 
toneal route.  The  section  is  made  in  a  fat  person,  and  therefore  shows  the  individual  layers  of  the  fascia  more 
widely  separated  than  usual. 


If  we  remove  the  intestines  and  study  the  configuration  of  the  posterior 
abdominal  wall,  we  find  the  various  depressions  shown  in  Fig.  321  (see  p.  609), 
constituting  niches  in  the  body  in  which  pus  is  apt  to  collect,  forming  well- 


612  ABSCE6S    IN    NEIGHBORHOOD   OF    APPENDIX. 

defined  abscesses.  There  arc,  in  general,  three  of  these  niches,  the  deep 
pelvic,  and  the  right  and  left  abdominal  respectively,  the  latter  of  which  may 
be  subdivided  again  into  iliac  below  and  renal  above. 

The  natural  tendency  of  pus  to  gravitate  upward  as  the  patient  lies  recum- 
bent will  be  best  understood  by  consulting  Fig.  322,  where  it  is  manifest  that 
the  posterior  abdominal  wall  is  disposed  on  an  inclined  plane  at  an  angle  of 
about  30  degrees.  The  upper  course  of  the  infection  is  facilitated  not  only  by 
gravity,  but  by  the  natural  drainage  of  the  lymphatics  in  this  direction. 

Fig.  323  shows  the  natural  tendency  of  an  abscess  to  pour  into  the  pelvis 
or  to  extend  up  under  the  layers  of  the  niesileum,  when  the  appendix  is  disposed 
as  represented  in  the  section.  It  is  also  evident  from  this  figure  that  an  infec- 
tion perforating  the  posterior  layers  of  the  fascia  is  not  only  in  a  position  to  invade 
the  upper  region,  as  shown  in  Fig.  322,  but  to  work  downward  under  Poupart's 
ligament   into  the  thigh 


REMOVAL  OF  THE  APPENDIX  IN  SUPPURATIVE  CASES. 

One  of  the  most  important  questions  connected  with  suppurative  peri- 
appendicitis (appendical  abscess)  is  the  treatment  of  the  appendix  itself.  In 
mosl  Cases,  especially  where  there  is  a  large  abscess,  ami  the  patient  is  exhaust eil 
by  the  disease,  the  best  plan  is  simply  to  lay  open  the  abdominal  wall  freely 
so  as  to  drain  off  the  pus,  and  to  pay  no  attention  to  the  appendix  whatever. 
Treated  in  this  way,  the  appendix  is  sometimes  discharged  as  a  slough  when  I  he 
dressings  are  changed,  or  as  the  wound  is  washed  out.  ( >r,  if  the  appendix  is  not 
seen  at  any  time,  it  may  be  so  greatly  obliterated  by  the  disease,  and  so  thoroughly 
incorporated  in  the  scar  tissue  of  the  contracting  abscess  cavity  that  it  causes 
no  future  harm.  When  the  appendix  is  clearly  exposed,  or  when  it  lies  at  some 
point  where  it  can  be  reached  without  risk  of  opening  the  peritoneal  cavity, — 
as,  for  example,  along  the  posterior  wall  of  the  fossa,  or  behind  or  to  the  outside 
of  the  cecum  or  colon. — the  surgeon  may  then  cautiously  expose  the  appendix 
from  end  to  end,  amputate  ami  remove  it.  Not  infrequently,  however,  in 
such  cases,  the  sutures  at  the  base,  closing  in  the  opening  into  the  cecum, 
refuse  to  hold,  and  the  result  is  a  discharge  of  fecal  matter  onto  the  dressings, 
lasting  for  a  few  days  or  weeks,  and  finally  disappearing  spontaneously;  a  fecal 
fistula  often  follows  the  simple  incision  of  an  abscess,  and  closes  without  further 
trouble,  after  a  short  interval. 

The  alternative  plan  is  that  of  hunting  for  the  appendix  in  the  abscess  cavity 
or  in  its  walls,  even  breaking  up  the  adhesions  which  form  the  walls  of  the  cavity 
in  the  determination  to  discover  and  remove  the  cause  of  the  trouble.  While 
there  can  be  no  objection  to  pulling  out  a  loosened  appendix  when  it  appears 
sloughing  and  gangrenous,  in  common  with  other  sloughing  tissues,  the  practice, 
once  so  widely  recommended  by  surgeons,  more  to  be  admired  for  their  courage 
than  their  discretion,  of  "always  removing  the  appendix,"  is  to-<lay  pretty 


SECOXDARY   OPERATION.  G13 

generally  condemned,  although  a  few  excellent  members  of  the  profession  still 
continue  it. 

It  is  encouraging  to  feel  assured  that  when  an  appendix  has  gone  so  fax  as 

to  produce  an  abscess  in  its  neighborhood,  it  is  itself,  in  most  instances,  so 
completely  disorganized  as  to  occasion  no  further  trouble.  The  advantage  of 
the  simple  incision  with  drainage  is  well  shown  by  Barling  (Lancet,  Feb.  22, 
1903),  who,  in  a  series  of  74  abscess  cases,  removed  the  appendix  in  only  25. 
The  remaining  49  cases,  where  the  appendix  was  left  undisturbed  were  kept 
under  observation,  and  in  only  one  was  there  a  recurrence  of  the  disease; 
this  one  was  then  operated  upon  successfully.  It  is  safe  to  assert  that  had  the 
surgeon  insisted  upon  finding  and  removing  the  appendix  in  the  49  cases,  he 
would  have  lost  a  large  percentage  of  them.  I  must  add  here,  however,  that 
there  have  been  two  fatal  cases  in  the  Johns  Hopkins  Hospital  from  a  recur- 
rence of  the  abscess  after  simple  incision.  The  balance-sheet,  however,  may 
be  said  to  be  overwhelmingly  in  favor  of  drainage  without  extirpation,  where 
the  latter  course  presents  any  serious  difficulty,  or  exposes  the  patient  to  the 
dangers  of  opening  the  free  peritoneum. 

Jaffe  (Berl.  klin.  Wochenschr.,  Dec.  14,  1903,  p.  1148),  out  of  100  cases  which 
were  opened  and  drained,  saw  only  5  in  which  it  was  necessary  to  remove  the 
appendix  at  a  later  date.  The  obliteration  and  destruction  of  the  appendix 
which  goes  on  concurrently  with  the  formation  of  an  abscess  is,  in  his  opinion, 
a  strong  argument  for  deferring  operation  in  those  cases  where  the  inflammatory 
process  is  manifestly  shut  off  from  the  peritoneal  cavity,  as  evidenced  by  the 
wall  of  adhesion  surrounding  it  on  all  sides  as  well  as  posteriorly,  a  wall  "as 
sharply  defined  as  the  margin  of  the  liver."  He  draws  attention  to  the  com- 
parative advantages  of  the  intermediate  operation,  pointing  out  that,  if  the 
operation  is  done  before  the  suppuration  of  the  entire  exudate  (" Falls  der  Kern 
des  perityphlitischen  Exudate  noch  nicht  eitriij  eingeschmolzen  ist"),  the  operator 
is  under  the  necessity  of  finding  the  appendix  in  the  midst  of  adherent 
intestines  and  scattered  deposits  of  pus,  fibrin,  and  exudate,  as  there  is  under 
such  conditions  no  assurance  that  the  peccant  organ  will  be  so  involved  in 
the  cicatrix  during  the  healing  process  as  to  become  harmless  for  the  future. 

Neumann  [Langenb.  Archiv  /.  klin.  Chir.,  1901,  Bd.  62,  lift.  3)  advocates 
the  plan  of  a  secondary  operation  for  removal  of  the  appendix,  after  the  draining 
of  the  abscess,  claiming  for  it  the  following  advantages: 

1.  The  duration  of  the  original  operation,  which  occurs  at  a  time  when  the 
patient  is  more  or  less  exhausted,  and  when  every  effort  should  be  used  to  sus- 
tain vitality,  is  much  shortened. 

2.  It  prevents  an  already  existing  peritonitis  from  spreading,  and  avoids 
exciting  a  fresh  peritonitis  by  exposing  closed  peritoneal  surfaces. 

3.  The  appendix  can  be  removed  at  the  secondary  operation  close  to  the 
cecum,  while  the  patient  is  in  good  condition  and  the  absorbing  power  of  the 
peritoneum  possesses  its  normal  activity. 


:'.l  1  ABSCESS   1\    NEIGHBORHOOD   OF   APPENDIX. 

1.  Adhesions  are  easily  freed  and  the  formation  <>f  fresh  ones  avoided. 

5.  The  risk  of  ventral  hernia  is  greatly  lessened. 

When  the  appendix  exceeds  the  normal  length,  and  the  diseased  area  is 
situated  in  the  tip,  the  location  of  the  abscess  may  he  more  or  less  distant  from 
the  usual  site  of  an  appendix.  The  same  unusual  location  is  found  when 
the  position  of  the  appendix  is  abnormal  from  congenital  displacement  of  the 
caput  coli.  especially  when  the  latter  is  high  up  behind  the  liver;  or  when  a 
previous  attack  of  inflammation,  resulting  in  contraction,  causes  upward  dis- 
placement of  the  cecum. 


TREATMENT  OF   ABSCESS. 

Evacuation. — The  best  place  to  open  an  abscess  is  at  the  site  indicated 
by  nature  through  swelling  and  tenderness.  A  free  incision  should  be  made 
over  the  location  of  the  pus  and  rather  to  the  outside,  near  Poupart's  liga- 
ment, or  the  spine  or  crest  of  the  ilium,  and  in  the  direction  of  the  external 
oblique  muscle.     Edema  of  tissues  under  the  skin,  or  beneath  the  muscles  is  an 

indication  of  pus  near  at  hand,  a  little  deeper  in.     It  is  ag 1  plan  to  pull  the 

muscles  widely  apart  without  cutting  them,  and  then  to  open  the  abscess  by 
a  blunt  dissection;  if  it  is  large  enough  to  need  a  freer  avenue  of  drainage,  an 
incision  can  be  made,  both  up  and  down,  through  the  entire  thickness  of  the 
abdominal  walls.  Fig.  324  shows  Weir's  method  of  securing  a  large  opening 
through  which  an  abscess  or  other  complication  may  be  dealt  with  without 
embarrassment  (Tran*.  Congres  internat.  de  mid.,  Paris.  1000.  p.  SOI). 
Doughty's  method  ^personal  communication)  of  securing  a  larger  avenue  of 
approach  and  a  better  opening  for  free  drainage  is  seen  in  Figs.  325,  326,  and 
327. 

It  is  sometimes  very  difficult  to  recognize  the  peritoneum  if  it  is  adherent, 
and  the  surgeon  should  then  use  a  fine  needle  or  the  point  of  a  knife  toenterthe 
abscess,  introducing  a  pair  of  artery  forceps  with  closed  blades  as  soon  as  the 
pus  appears,  and  spreading  the  blades  apart  after  they  are  inserted  ;  the  forceps 
is  then  withdrawn  and  the  fingers  inserted,  in  order  to  keep  the  hole  widely 
open,  and  give  the  pus  free  exit.  If  there  is  any  suspicion  of  the  peritoneum, 
it  is  best  to  work  carefully  backward  on  the  outer  side  toward  the  flank  in  order 
to  open  the  abscess  without  disturbing  the  peritoneum  (see  Fig.  328,  p.  617).  If 
the  unopened  peritoneum  is  found  freely  movable  over  the  mass,  the  surgeon  has 
a  choice  between  several  plans  of  procedure.  First,  the  peritoneum  may  be 
gently  pushed  toward  the  median  line,  until  the  mass  is  reached  extra-perito- 
neally,  as  just  described.  Second,  the  mass  is  reached  extra-peritoneally  in  a 
similar  manner,  after  it  has  first  been  thoroughly  explored  through  an  incision 
opening  into  the  peritoneal  cavity;  this  opening  ought  to  be  closed  before  break- 
ing into  the  abscess  from  the  lateral  extra-peritoneal  route;  such  an  opening 
clears  up  the  diagnosis  as  to  the  extent  of  the  trouble  and  points  out  the  safe 


EVACUATION   OP"  ABSCESS. 


615 


way  for  the  evacuation.  Third,  the  abscess  may  be  emptied  trans-peritoneally 
(see  Fig.  329,  p.  617).  This  last  method  gives  visual  command  of  the  field,  and 
better  control  of  all  possible  conditions  and  complications  that  may  arise,  and  for 
many  cases  with  abscesses  awkwardly  disposed  toward  the  interior  of  the  abdo- 
men, it  is  the  plan  to  be  preferred.     It  is  contraindicated  for  very  weak  patients, 


Fir..  :?._'4. —  Weir's  Incision"  for  the  Purpose  of  Enlarging  the  MgRirnky  Opening  withoi  t  Dividing  the 

M  L"  SCLES. 

The  skin  incision  and  The  reparation  of  the  external  oblique  fibres  are  made  obliquely  downward  across  the 
semilunar  line.     The  rectus,  with  the  epigastric  vessels,  is  thus  exposed  and  can  be  retracted.     The  interna 
lique  transversalis  and  posterior  lamella  of  rectus  sheath  with  the  peritoneum  are  then  divide!,  giving  abundant 
room,  as  shown,  for  dealing  with  complication.     The  figure  does  not  represent  the  maximum  space  which  can  be 
secured  by  drawing  the  transversalis  fascia  strongly  up  and  down. 


whose  vitality  is  better  conserved  by  a  simple  extra-peritoneal  evacuation  of 
the  pus.  For  such  a  trans-peritoneal  treatment  a  long  vertical  incision  is  made, 
either  near  the  rectus  or  through  its  fibrous  sheath,  so  as  to  deliberately  expose 
the  mass  on  the  median  aspect.  The  swelling  is  then  carefully  outlined  by 
sight  and  touch,  and  then  an  efficient]  protective  hairier  is  formed  about  the 


till) 


ABSCESS    IN     \KI<;  II  Itui;  n<  h  >i>    OF    APPENDIX. 


Ext     oblique 


Inc.  thr.    sheath   of  reclus, 


Ant.  sup  spine 


Fig.  325.— Doughty's   Method  for  Securing   More   Room   in   Arspess  and  other   DlPFlCULT  Cases. 
The  incision  is  made  in  thr  skin  in  an  oblique  direct  inn.      The  external  oblique  fibres  are  t  hen  separated,  and 
afteru  an  I-  those  of  the  internal  oblique  and  t  ransversalis.     This  opening  is  enlarged  with  scissors  until  t  lie  clue  of 
the  rectus  is  exposed.     The  layers  of  the  sheaths  of  the  rectus  are  then  cut  up  and  down,  as  indicated. 


Fig.  326. — The   Triangular    Flaps   This   Formed   are    Drawn    Up   and    Down,   Giving   a    Wide   Area   of 

Exposure  to  the  Peritoneum. 
If  the  wound  is  to  remain  open  for  packing,  the  several  structures  are  identified  by  loop-,  of  silk. 


EVACUATION    OF   ABSCESS. 


617 


Fig.  327. — Doughty's  Method 
Shows  the  Complete  Closure 
of  the  Wound  and  the  Rela- 
tions of  the  Lines  of  Sutur- 
ing. 


Fig.  328. — Diagram  Showing  the  Method  of  Approaching  the 
Abscess  by  the  Extra-peritoneal  Route.     (See  p.  614.) 


Fig.  329. — Shows  the  Transperitoneal  Method,  Packing  off  the  Uncontaminated  Peritoneum  on  all 
Sides  in  Order  to  Approach,  Evacuate,  Clean  out,  and  Drain  the  Abscess  by  this  Route. 


618 


ABSCESS    IX    XEMWIBOIMIOOM    m|      U'l'HXDIX. 


mass,  by  means  of  pads  of   folded   gauze,  which   holds  back   every   loop  of 
the  healthy  bowel,  and  protects  the  abdominal  cavity  above,  toward  the  middle 


Above  &  behind 

ti  vct- 


In  t.  ren*l  -eg. or. 


Pio.  330- — Showing  the  VARiors  Sites  at  which  Ahs*  i  sse«  are  More  Commo.vut  Found. 
The  appendix  is  seen  below  on  the  righl  in  the  centre  of  a  chain  of  abscesses  which  extend  upward  on  the 
right  into  renal  region,  supra-hepatic  and  right  pleural,  or  into  'lie  liver  by  portal  vein.  Use  extension  up  the 
lit*  nje  i-  usually  effecte'l  by  traversing  the  pelvis,  the  left  iliac  fossa,  and  the  left  renal  fossa.  Occasionally  the 
absees-  i  found  located  among  the  intestines  in  the  neighborhood  of  the  umbilicus,  and,  rarely,  in  the  splenic 
region 


line,  and  in  the  true  pelvis.     Before  opening  the  abscess  a  few  large  strips  of 
dry  iodoform  gauze  may  be  loosely  laid  about  the  point  of  evacuation.     The 


CLEANSING    ABSCESS    CAVITY.  Ii]!l 

cecum  is  carefully  raised,  and  as  the  pus  appears  it  is  taken  up  with  small 
sponges.  The  iodoform  strips  may  be  removed  and  replaced  as  rapidly  as  they 
are  soiled.  When  all  the  pus  and  fibrin  that  the  gauze  sponges  will  remove 
have  been  taken  up,  the  appendix  is  dealt  with  as  best  suits  the  case.  After  its 
exposure,  a  large  abscess  is  often  best  treated  by  aspiration,  to  take  off  the 
tension  and  the  excess  of  pus;  it  may  then  be  opened  and  cleaned,  the  ap- 
pendix being  removed,  if  it  is  accessible.  Other  foci  of  pus  should  then  be 
carefully  evacuated  in  the  same  way. 

If  a  second  mass  is  found  in  the  lumbar  region  or  in  the  pelvis,  it  may  be 
best  to  make  a  separate  incision  or  a  counter-opening  at  the  nearest  point  on 
the  abdominal  wall.  In  women,  vaginal  puncture  and  free  drainage  are  often 
most  useful,  and  in  men  a  similar  puncture  through  the  rectum  is  occasionally 
of  great  service. 

After  evacuating  all  pus  and  thoroughly  opening  and  cleansing  the  cavities 
with  dry  gauze,  the  infected  areas  should  be  loosely  packed  with  washed-out 
iodoform  gauze  ('Sanger).  The  protective  gauze  pad  may  then  lie  withdrawn, 
and  the  wound  closed  with  a  wide  opening  for  the  exit  of  the  iodoform  gauze. 
After  emptying  the  right  iliac  abscess,  the  surgeon  must  carefully  palpate 
the  adjacent  accessible  regions,  within  the  limits  of  safety,  in  order  to  dis- 
cover any  communicating  or  secondary  abscesses,  which  may  be  found  at  any 
of  the  points  shown  in  Fig.  330.  He  should  also  bear  these  regions  in  mind 
throughout  the  convalescence. 

Cleansing  the  Abscess  Cavity. — Too  much  stress  cannot  be  laid  upon  the 
necessity  for  care  and  dexterity  at  this  stage.  AYalsham  (Treatise  on  Appendici- 
tis, 1901,  p.  22)  cites  a  good  example  of  the  harm  which  may  result  from  any 
but  the  gentlest  manipulation.  A  boy,  aged  seventeen,  was  admitted  to  hospital 
with  acute  appendicitis,  on  the  seventh  day  of  the  disease.  An  incision,  about 
one  and  a  half  inches  long,  was  made  just  above  the  outer  part  of  Poupart's 
ligament,  and  a  localized  abscess  containing  two  ounces  of  pus  was  opened. 
A  finger  was  then  introduced  to  explore  the  abscess,  and  the  latter  was  washed 
out.  The  temperature  and  pulse  both  rose  gradually  after  the  operation,  the 
patient  became  very  restless  and  died  on  the  second  day.  The  postmortem, 
which  showed  that  the  appendix  was  ulcerated  and  contained  a  concretion, 
also  showed  that  a  hole  had  been  accidentally  made  through  the  adhesions  into 
that  part  of  the  peritoneal  cavity  which  had  been  previously  healthy,  and  that 
through  this  hole,  pus  and  lotion  had  been  injected  into  the  general  peritoneum, 
thus  setting  up  septic  peritonitis!  After  the  abscess  is  evacuated  and  wiped 
dry,  it  is  often  advantageous,  especially  if  the  cavity  is  a  small  one,  to  sterilize 
it  as  thoroughly  as  possible.  This  may  be  done  by  means  of  a  strong  antiseptic 
solution  applied  for  a  brief  space  of  time  and  wiped  off.  For  a  small  abscess 
pure  carbolic  acid  is  most  efficient,  applied  on  a  little  pledget  of  cotton,  care 
being  taken  that  no  excess  of  acid  is  allowed  to  run  over  the  adjacent  tissues; 
if  this  is  followed  by  an  application  of  pure  alcohol,  no  harm  ought  to  result 


620  ABSCESS    IN    NEIGHBORHOOD   OF    APPENDIX. 

from  its  escharotie  tendency:   great   caution,  however,  must  be  used,  u    lhe 
proximity  of  the  iliac  vessels,  or  in  applying  it  on  the  bowel.    This  I'c 

treatment  is  best  suited  to  small  indurated  cavities  containing  a  little  pus,  wl 
are  attached  to  the  cecum,  lie  behind  it,  or  are  lodged  in  the  true  pelvis.      I.:. 
abscesses    I    swab    out    with    a    solution    of    mercuric   chloride    (1:1000),   ". 

solution  of  formalin  followed  by  plain  water.      Fetid  abscesses  may  be  elea!:- "-•■ 

with  peroxide  of  hydrogen. 

Drainage. — An  abscess  cavity  should  never  be  disinfected  and  closed  wi  ,i- 
out  drainage.  When  there  has  been  much  pus,  a  large  opening  ought  te  be 
left  for  free  drainage:  but  before  the  drain  is  inserted,  the  relations  of  the 
abscess  must  be  studied,  and  pressure  made  upon  it  in  various  directions,  in 
order  to  ascertain  that  there  is  not  some  other  cavity  communicating  with  the 
primary  one.  If  there  is,  it  should  be  explored  to  its  bottom,  ami,  if  it  extends 
into  any  other  dependent  position,  such  as  the  right  renal  region,  or  the  floor 
of  the  pelvis,  a  counter-opening  should  be  made  there  also.  The  pelvis,  in  par- 
ticular, should  be  carefully  explored,  to  discover  a  possible  h  o  u  r  -  g  1  ,.  s  s 
abscess,  that  is  to  say.  an  abscess  of  the  iliac  fossa  communicating  with 
thr  pelvis,  often  by  a  narrow  and  almost  imperceptible  orifice  or  ch  nnel,  which 
is  one  of  the  most  dangerous  of  all  forms  of  secondary  abscesse  .  Douglas' 
dd-de-sac  should  always  be  explored,  when  there  are  no  adhesions  to  contra- 
indicate  it,  by  the  introduction  of  gauze  on  a  probe. 

The  essential  points  to  be  remembered  in  drainage  are  these: 

The  drain  is  only  a  drain  to  a  limited  extent  and  for  a  short  time;  it  act- 
chiefly  as  a  protective  pack. 

It   is  essential  that  the  whole  septic  area  should  be  drained. 

The  drain  must  be  loose  in  order  that  it  may  absorb  rapidly.  It  must  never 
be  firmly  packed. 

The  drain  must  have  exit  through  a  large  orifice. 

Whenever  possible,  the  drain  must  be  to  an  orifice  in  a  dependent  position. 

The  drain  must  be  watched,  and  as  soon  as  it  ceases  to  discharge  it  must  be 
loosened  or  wholly  withdrawn. 

In  a  small  abscess  it  is  sometimes  best  to  leave  the  drain  in  for  a  week.  Fatal 
infection  has  occurred  from  removing  it  too  soon  and  thus  breaking  up  pro- 
tective adhesions. 

One  of  the  most  dangerous  forms  of  abscess  is  that  in  which  there  is  a  small 
accumulation  of  pus,  it  may  be  not  more  than  a  few  drops,  walled  off  about  the 
tip  of  the  appendix.  Such  cases  are  oftenesf  found  at  the  tip  of  an  appendix 
dipping  into  the  pelvis;  Fig.  331  represents  one  of  these  abscesses  high  up  in 
the  neighborhood  of  the  hepatic  flexure.  The  danger  lies  in  the  fact  that 
the  operator  is  tempted  either  to  cleanse  the  cavity  and  close  it  entirely,  or 
to  attempt  to  get  along  with  insufficient  drainage  by  a  long  and  circuitous  route. 
It  is  imperative  that  operators  should  confer  upon  these  minute  abscesses  all 
the  dignity  of  the  larger  form,  treating  them  with  the  most  extreme  care  to 


DRAINAGE    OF    ABSCESS. 


621 


av^:''  any  contamination  of  the  peritoneum,  sterilizing  the  cavity  with  pains- 

^  care,  introducing  an  abundant  gauze  drain,  which  should  be  left  in  for 

or  six  days,  and,  lastly,  draining  onto  the  surface  by  the  mosl  direct  avenue, 

n  if  it  is  necessary  to  make  an  additional  incision,  or  to  enlarge  the  incision 

ady  made.     Fig.  332  shows  the  cause  of  the  minute  abscess,  namely,  a 

.■.i-point  perforation  of  the  tip  of  the  appendix. 

The  best  material  for  drainage  is  washed-out  iodoform  gauze,  used  in  strips 
i  j  or  three  inches  wide  and  about  twenty  inches  long,  and  in  two  or  three 
tl.  '(messes.  Before  introducing  the  drain,  all  sound  bowel  should  be  lifted 
Uji  en  masse  to  one  side,  and  held  off  from  the  abdominal  parietes;  then,  with 
the  abscess  cavity  freely  exposed,  it  is  loosely  filled  with  strips  of  gauze.     If 


Fig.  331- — Downes'  Case  Showing  the  Unusual 
Location*  of  the  Abscess  high  op  to  the  Inner 
Side  of  the  Ascending  Colon,  Covered  by  the 
Omentum.     Recovery. 


Fig.  3.32. — Downes'  Case  of  Pin-point  Perfora- 
tion, a.  of  the  Tip  of  the  Appendix:  b, 
Ragged  Area  of  Adhesions  Walling  off  Ab- 
scess.     (Natural  size.) 


the  abscess  is  in  the  pelvis,  it  should  be  loosely  stuffed  on  all  sides,  in  such  a 
manner  that  the  sound  bowel  rests  upon  the  gauze.  Great  care  must  be 
exercised  in  introducing  the  gauze,  for  many  cases  have  been  lost  from  a  kink 
in  the  bowel  after  operation  resulting  in  an  obstruction.  According  to  Hal- 
sted,  a  small  drain  may  be  more  effective  in  causing  the  kink  than  a  large 
one.  The  packing  should  always  keep  the  intestines  away  from  the  drainage 
area  as  one  solid  organ,  and  the  gauze  must  not  be  left  among  the  coils.  For 
this  purpose  "the  cigarette  drains"  used  by  Morris  and  by  "Warrkx  (see 
]).  653)  are  very  satisfactory. 

The  size  of  the  drain  must  depend  upon  the  nature  of  the  infection. 
During  operation  a  smear  should  be  taken,  and  if  nothing  is  found  except  the 
colon     bacillus    there    is    no   reason    for   special  caution;    if,    however, 


622  ABSCESS    l\    NEIGHBORHOOD   OP  APPENDIX. 

the  streptococcus  or  staphylococcus  is  present,  there  must 
be  a  wide  drain  with  everything  left  open.  The  drain  may  remain  un- 
touched from  five  to  seven  days,  or  longer,  provided  the  patient  is  improving. 
As  long  as  there  is  a  free  flow  from  the  wound,  it  need  not  be  disturbed.  It 
should  not  be  removed  on  account  of  an  elevation  of  temperature  during  the 
firsl  day  or  two,  when  the  patienl  is  otherwise  doing  well,  as  this  is  usual. 

In  removing  the  gauze,  it  is  well  to  use  traction  forceps  in  order  thai  it  may 
be  drawn  out  steadily  and  slowly.  If  there  is  much  pain  in  doing  this,  nitrous 
oxid  gas  may  be  administered.  The  second  tampon  should  be  much  smaller 
than  the  first,  in  order  to  favor  the  collapse  of  the  abscess  cavity.  The  external 
skin  opening  of  the  drain  must  always  be  kept  freely  open,  and  the  gauze  should 
ii'-'  er  he  allowed  to  plug  the  orifice  and  bottle  up  the  secretions.  If  necessary, 
a  hot  saline  poultice  may  be  used  to  soften  the  gauze  and  facilitate  its  removal. 


TREATMENT  OF  ABSCESS  IN  SPECIAL  CASES. 

In  some  unusual  eases  I  have  adopted  the  plan  of  opening  the  abdomen 
in  the  median,  right,  semilunar  line,  and  then,  when  the  alwv-  i<  located,  and 
found  accessible  by  an  extra-peritoneal  route.  I  have  made  a  second  incision 
in  the  skin,  close  to  the  crural  arch  (Fig.  333),  or  to  the  spine  of  the  ilium,  and 
worked  up  beneath  the  peritoneum  until  the  abscess  was  reached  and  evacuated, 
one  hand  acting  through  the  second  incision,  and  being  guided  by  the  other 
hand  and  the  eye  acting  through  the  firsl  (Fig.  334).  After  evacuation  of  the 
abscess,  every  adjacent  part  must  be  examined  by  bimanual  palpation  with 
the  hand  inside  to  discover  any  remaining  foci  of  pus.  The  clean  abdominal 
wound  must  then  be  closed  by  an  assistant  who  has  not  been  contaminated, 
or,  if  it  is  done  by  the  operator  himself,  lie  must  first  change  his  glove;  the 
lateral  incision  is  left  open  for  drainage. 

The  most  favorable  of  all  abscesses  are  those  encapsulated  in  the  omentum 
(see  Figs.  335  and  33f>.  pp.  lil'.")  and  626),  and  in  some  such  eases  it  is  possible 
to  excise  the  whole  abscess  cavity  enclosed  in  the  omentum,  and  close  the  wound 
without  drainage.  Van  Hook,  on  opening  the  peritoneum  in  a  case  protected 
by  the  omentum,  found  a  layer  of  it  lying  between  the  tumor  and  the  abdom- 
inal wall.  He  stitched  the  omentum  to  the  parietal  peritoneum,  and  the  next 
day  he  ojjened  the  pus  cavity.     The  patient  made  a  good  recovery. 

Abscess  Connected  w  i  t  h  a  G a  n  g  r e n  o u  s  A  p  p  e  n d  i  x  . — 
Terries,  who  has  insisted  with  great  emphasis  {Rev.  de  chir.,  Jan.,  1900)  upon 
the  importance  of  certain  a  na  erobic  ba  eilli  as  a  causative  factor  in  some 
of  the  worst  forms  of  appendicitis,  especially  the  gangrenous,  points  out  that  the 
suppurative  processes  due  to  these  bacilli  can  be  recognized  by  their  extreme 
fetidity,  and  that  they  rapidly  produce  the  gravest  lesions.  The  temperature  in 
a  case  of  this  kind  is  apt  to  be  low,  while  the  pulse  runs  up,  it  may  be  as  high  as 
140,  and  the  case  presents  all  the  appearance  of  a  rapid  and  grave  intoxication. 


TREATMENT     OF     ABSCESS     IX     SPECIAL     CASES. 


623 


Terrier  anticipates  that  the  study  of  this  new  class  of  organisms  in  their  rela- 
tion to  appendicitis  will  disclose  a  near  connection  between  clinical  forms  of 
appendicitis  and  the  bacterial  agents  at  work  in  their  causation.  He  also  be- 
lieves that  the  local  phenomena  in  such  cases  as  he  describes  will  eventually 
be  shown  to  depend  upon  the  specific  infection  rather  than  upon  special  ana- 
tomic considerations  ("  Recherche*  sur  quelques  microbes  strictement  anerobic  et 
leur  role  dans  pathologic''  Arch,  de  med.  exper.,  July,  1898,  p.  517).     The  under- 


Fig.  333. — Shows  the  Method  of  Exposing  an  Abscess  by  an  Incision  in  the  Right  Semilunar  or  Median- 
Line  and  then  Opening  and  Evacuating  it  Extra-petutoneally  by  a  Second  Smaller  Incision  in 
the  Right  Loin. 


standing  of  the  anaerobic  nature  of  some  of  the  worst  infections  leads  to  one 
deduction  of  great  practical  importance,  namely,  the  necessity  in  such  cases 
for  opening  the  wound  largely  and  using  peroxide  of  hydrogen  in  dressing 
all  infected  parts.  In  one  of  the  cases  cited  by  Terrier,  where  there  was  a  fetid 
suppuration  and  sloughing  of  the  whole  appendix  due  to  anaerobic  infection, 
a  gangrenous  phlegmon  was  found  in  the  abdominal  wall,  and  the  patient's 
life  was  only  saved  by  extensive  incisions  in  the  tissues,  begun  at  the  earliest 
possible  moment  and  repeated  several  times  in  the  effort  to  combat  the  rapidly 


624 


\HSCKSS    IN    NF.IGHHOKHOO!)    OF    AH'I'.NDIX. 


invading  gaseous  gangrene.  The  necrosed  cartilages  of  several  ribs  had  to  lie 
resected  in  treating  the  last  focus  of  suppuration.  Peroxide  of  hydrogen  was 
repeatedly  and  extensively  used  in  association  with  the  aggressive  surgical 

treatment. 

Another  dangerous,  hut  fortunately  rare  form  of  abscess,  is  that  occurring 


Fig.  334. — Shows  the  Hand  within  the  Abdomen  Guiding  and  CoNTBOLLlNa  thi    Forcbps  i\  ink  Act  of 
Opening  a\i>   Evacuating   the  Abscess  through  the  Lateral  [ncision. 


between  the  layers  of  the  mesentery  of  the  small  intestine.  An  interesting 
case  of  the  kind  is  reported  by  J.  C.  Bloodgood  (Jour.  Med.  Sri.,  1903)  in  which 
the  appropriate   treatment   is  incidentally  demonstrated. 

The  patient,  a  little  cirl.  eight  years  old,  was  taken  ill  with  severe  abdominal 
pain   referred  to  the  umbilical  region,  without  nausea  and  vomiting.     The  tern- 


TREATMENT   OF   ABSCESS   IN   SPECIAL   CASES. 


625 


perature  was  101°  F.;  the  puLse  110;  the  respiration  24  to  30  and  chiefly  thoracic. 
The  abdomen  was  slightly  distended;  both  recti  were  rigid;  there  was  muscle  spasm 
in  both  iliac  fossae,  slightly  more  marked  in  the  right.     In  the  umbilical  and  upper 


Fig.  335. — Appendix  and  Cecum  are  Wrapped  in  Omental  Adhesions. 
The  luwer  figure  shows  the  perforated  appendix  removed  with   the  attached  omentum.     A.,  San.  No.   1314. 
March,  1902.     Recovery.     (Natural  size.)     (See  p.  622.) 


hypogastric  regions  the  percussion  note  was  a  little  duller,  and  here  the  pain  and 
tenderness  were  most  acute.     There  were  no  symptoms  of  obstruction.     Under 
anesthesia  a  tumor  the  size  of  two  fists  could  be  felt  in  the  middle  zone  of  the  ab- 
40 


626 


IBSCESS    IN    NKKillltOHHOOD    OF   APPENDIX. 


domen.  (>n  section  of  the  abdomen,  a  mass  was  found  beginning  at  the  cecum 
and  extending  to  the  third  Lumbar  vertebra,  between  the  folds  of  mesentery.  There 
was  sufficienl  exudate  in  the  mesocolon  at  the  junction  of  the  cecum,  ileum  and 
appendix  to  obliterate  the  appendix.  There  was  no  exudate  in  the  mesocolon 
behind  the  cecum.  A  large  abscess  cavity  was  found  between  the  folds  of  the 
mesentery   extending  toward  the  vertebral  column.      The  intestines  were  pushed 


'f- 


Pig.  336. — Follis'  Case.  Gangrene,  Abscess,  and  Perforation  of  the  Appendix  as  Seen  in  the  Right- 
hand  Figure,  Completely  Enveloped  and  Protected  from  Peritoneal  Cavity  by  Omentum  as  Shown 
in  Left-hand  Figure. 

The  omentum  formed  a  tight  constricting  neck  around  the  appendix  beyond  the  disease.     R.,  boy  thirteen  years. 
Nov.  23,  1903.     Recovery.     (Natural  size.)    (See  p.  622.) 


aside,  the  peritoneal  cavity  walled  off  with  gauze,  and  the  abscess  drained.  Obstruc- 
tion developed,  however,  from  the  firm  packing  of  the  gauze,  and  in  a  second  opera- 
tion an  unsuccessful  attempt  was  made  to  drain  through  a  second  incision  to  the 
outer  side  of  the  cecum,  [n  removing  some  of  the  primary  packing  of  the  abscess 
cavity,  several  round  worms  were  extracted.  A  loop  of  presenting  small  intestine 
was  then  opened,  and  after  gas  and  thin  fecal  matter  had  been  evacuated,  a  fecal 


PELVIC   APPENDICAL   ABSCESS.  627 

fistula  was  established.  It  was  finally  found  possible  to  establish  a  permanent 
intestinal  anastomosis,  and  the  patient  eventually  recovered  completely,  although 

there  were  a  number  of  very  distressing  symptoms,  in  particular  those  of  starva- 
tion, owing  to  the  high  opening  in  the  small  intestine,  while  associated  with  these, 
there  was  marked  mental  disturbance,  during  which  the  child  had  to  be  restrained 
by  a  strait-jacket. 

PELVIC  APPENDICAL  ABSCESS. 

Archibald  (Montreal  Med.  Jour.,  1S90,  p.  SI),  in  22  cases  of  abscess  origi- 
nating in  the  appendix,  found  7  situated  in  the  pelvis.  Rottek  (Dtsch.  med. 
Woch.,  1890,  No.  39),  out  of  132  abscesses  starting  in  the  appendix,  found  40 
which  were  pelvic,  and  of  these  40  cases,  there  were  27  in  which  the  appendix 
itself  was  located  in  the  pelvis.  In  21  cases  out  of  the  40,  the  pus  was  situated 
in  the  pelvis  alone,  while  in  the  remaining  19,  the  pelvic  abscess  was  associated 
with  an  extension  into  other  regions.  Out  of  the  21  cases  in  which  the  abscess 
was  confined  to  the  pelvis,  there  were  7  in  which  it  was  concealed  in  the  true 
pelvis,  and  not  perceptible  to  abdominal  examination,  but  in  14  cases  it  could 
be  felt  through  the  abdominal  walls.  In  the  19  cases  of  pelvic  abscess 
with  extension,  the  right  iliac  fossa  was  the  seat  of  the  second  abscess  14  times, 
and  in  every  instance  the  iliac  abscess  was  isolated  from  the  pelvic.  In  3  cases 
the  extension  of  suppuration  was  into  the  left  iliac  fossa.  Out  of  24  pelvic 
abscesses  collected  by  Berard  and  Patel,  the  suppurative  process  was  con- 
fined to  the  pelvis  in  11  cases:  in  7  there  was  an  avenue  of  communication 
between  the  iliac  and  pelvic  abscesses;  in  4  the  pelvic  suppuration  was  secon- 
dary to  iliac  abscess;  and  in  2  there  was  a  pelvic  abscess  with  bilateral  iliac 
diverticula.  Berard  and  Patel  divide  these  pelvic  abscesses  into  two  classes: 
the  p  e  r  i  -  a  p  p  e  n  d  i  c  a  1  ,  in  which  there  is  a  direct  connection  with  the  ab- 
scess surrounding  the  appendix;  and  the  p  a  r  a  -  a  p  p  e  n  d  i  c  a  1 ,  in  which 
the  appendix  is  situated  above  the  pelvic  brim,  and  has  no  apparent  direct 
communication  with  the  abscess. 

Sometimes  there  are  two  abscesses,  one  surrounding  the  appendix  on  the 
iliac  fossa,  and  another  filling  the  pelvis;  these  may  be  entirely  distinct  from 
each  other,  or  they  may  communicate  more  or  less  freely  over  the  brim  of  the 
pelvis  under  the  adherent  coils  of  intestines.  A.  C.  Bernays,  of  St.  Louis,  has 
employed  a  method  which  throws  light  on  the  mode  of  origin  of  pelvic  abscesses. 
In  an  incipient  peritoneal  infection  without  pus,  he  always  introduces  along 
glass  pipette  as  far  as  the  floor  of  the  pelvis  and  catches  the  secretion 
from  there,  in  which  he  almost  invariably  finds  abundant  bacterial  flora,  which 
develop  on  suitable  media. 

BROCA  (Bull,  tried..  June  29.  1901,  p.  589)  distinguishes  two  sorts  of 
abscesses  under  the  title  superior  and  inferior  pelvic.  Supe- 
rior pelvic  abscesses  start  near  the  superior  strait,  in  which 
situation  they  may  be  quite   out    of  reach    in  an  examination    through    the 


628  ABSCESS  l\  NEIGHBORHOOD  OF   APPENDIX. 

abdomen,  or  by  the  rectum.  Later  on,  as  they  develop,  they  become  iliac,  or 
again  pelvic,  or  at  once  both  iliac  and  pelvic.  Inferior  pelvic 
a  lis  cesses  cannot  lie  detected  by  an  examination  from  above,  but  they 
are  perceptible  to  the  rectal  touch,  as  they  generally  lie  in  close  association 
with  the  anterior  wall  of  the  rectum.  In  rare  instances  the  sigmoid  flexure 
lies  between  such  a  collection  of  pus  and  the  rectal  wall.  These  pelvic  abscesses 
are  walled  off  from  the  general  peritoneal  cavity  by  a  layer  of  adhesions 
uniting  the  small  intestines  one  to  another. 

Sometimes  after  the  disappearance  of  an  acute  appendicitis,  rectal  palpation 
reveals  a  line  of  infiltration  against  the  pelvic  wall,  and  possibly  a  very  tender 
spot  in  the  wall  of  the  bowel.  The  patient  may  also  complain  of  severe  pain 
on  straining  in  the  evacuation  of  the  bowels.  These  signs  point  to  an  appendix 
hanging  over  the  brim  into  the  pelvis,  and  attached  to  the  rectum. 

Symptoms. — The  special  symptoms  of  pelvic  abscess  are  radiation  of  the 
pain  down  the  right  leg,  McBurney's  point  being  generally  painless,  as  the  pus  is 
located  lower  down;  but  mosl  characteristic  of  all,  are  the  signs  of  pelvic  perito- 
nitis, consisting  of  vesical  and  rectal  disturbanc  e  s  .  The  ves- 
ical disturbance  sometimes  amounts  to  little  more  than  frequent  or  painful  mic- 
turition. In  other  cases  there  is  decided  tenesmus,  noted  soon  after  the  beginning 
of  the  attack.  Retention  of  the  urine  has  also  been  observed  in  some  instances. 
Electa!  tenesmus  is  a  frequent  sign,  beginning  generally  on  the  second  day 
and  lasting  for  a  short  period.  In  some  cases  there  is  a  discharge  of  mucus  by 
the  rectum.  In  two  instances  a  diagnosis  of  nephritic  colic  has  been  made 
on  account  of  the  pain  radiating  down  the  inguinal  region  and  into  the 
testicle  ("De  I'appendiciie  pelvienne,"  Chevalier,  Paris,  1900).  In  another 
instance  anuria  coexisting  with  tenesmus  and  hypogastric  swelling  gave  rise 
to  a  diagnosis  of  retention  of  urine.  An  important  means  of  recognizing  the 
involvement  of  the  appendix  is  through  the  radiation  of  the  pain  toward  the 
umbilicus,  when  pressure  is  made  over  the  position  of  the  diseased  appendix. 

Treatment. — The  recognition  of  pelvic  abscess  is  essential  to  its  proper  treat- 
ment and  is,  therefore,  of  greal  importance.  One  of  the  most  important  avenues 
for  opening,  evacuating,  and  draining  an  abscess  'm  the  region  of  the  appendix- 
is  through  the  rectum.  The  rectal  passage  is  a  particularly  satisfactory 
method  in  men,  in  young  women,  and  in  children,  and  is  especially  suitable  in 
all  cases  of  large  pelvic  abscess  filling  the  pelvis,  as  well  as  in  all  those  in  which 
an  abscess  actually  points  in  the  bowel.  In  advanced  cases  rectal  evacuation 
has  the  advantage  of  causing  little  shock  to  the  patient,  while  at  the  same  time 
it  offers  the  greatest  of  all  desiderata,  namely,  an  opening  at  the  bottom  of  the 
area  to  be  drained;  whenever  it  is  possible,  by  making  an  opening  posterior  to 
the  cervix  uteri  or  into  the  rectum,  to  secure  drainage  in  a  dependent  position, 
the  abscess  will  lie  better  drained  than  when  the  opening  is  made  above,  through 
the  abdominal   wall. 


PELVIC   APl'lONDICAL  ABSCESS. 


629 


In  a  married  woman,  especially  in  a  multipara,  the  retro-uterine  peritoneal 
pouch  affords  a  most  convenient  avenue  for  drainage  by  the  vagina,  which 
is  at  the  same  time  free  from  any  objection  on  the  score  of  contamination  from 
fecal  discharges.  "When  the  abscess  can  lie  felt  through  the  posterior  cul-de- 
sac,  this  should  in  all  instances  be  opened.  The  operation  is  done  by  re- 
tracting the  posterior  vaginal  wall  so  as  to  expose  the  vault;  the  cervix  is 
then  caught  and  drawn  forward,  while  the  vaginal  vault  just  behind  the  cervix 
is  laid  open  from  side  to  side  with  scissors  or  knife.  As  soon  as  the  bulging 
peritoneum  is  reached,  it  is  opened  widely  and  then  stretched  to  a  maximum 
from  side  to  side  by  hooking  in  the  right  and  left  index-fingers.     This  gives 


Fig.  337. — Gallant's  case.  Large  retn>-peritnneal  abscess  in  a  kiiI  ten  years  old  extending  from  the  region 
of  the  appendix  behind  the  pelvic  peritoneum  and  pointing  back  of  the  cervix  uteri,  where  it  bulges  into  the 
vagina.     Vaginal  drainage  impossible  on  account  of  age  of  patient.      Drainage  above.     Recovery. 

free  exit  to  all  the  discharges,  ami  the  cavity  maybe  carefully  washed  out,  a 
rubber  tube  being  inserted  with  a  loose  pack  of  iodoform  gauze.  In  a  child 
either  the  rectum  or  the  superior  strait  must  be  utilized  (see  Fig.  337). 

When  the  abscess  is  located  entirely  in  the  pelvis,  the  indication  is  to  find 
the  point  of  least  resistance  through  the  inferior  strait,  and  to  make  an  opening 
there.  To  evacuate  a  collection  of  pus  by  separating  the  agglutinated  intestine 
through  the  superior  strait  is  exceedingly  dangerous.  Qikxu's  method,  in  two 
steps,  is  also  not  to  be  recommended,  if  the  collection  can  be  reached  from  below. 
The  first  step  in  his  procedure  is  to  open  the  peritoneal  cavity,  locate  the  abscess, 


030 


AHSCKSS    IN    XTKHJHBOUH OF    APPENDIX. 


ami  introduce  the  tampon  down  to  it,  so  as  to  establish  an  avenue  for  the 
escape  of  the  pus.    The  next  step  is  to  open  the  abscess  at  a  later  date. 

It  sometimes  happens  that  an  operator  is  surprised  upon  opening  the  abdo- 
men to  discover,  as  in  Cullen's  case  (Fig.  338),  a  large  accumulation  of  pus 
in  the  pelvis,  the  exact  position  and  size  of  which  are  only  known  after  sufficient 
adhesions  have  been  separated  to  release  the  pus  and  make  it  imperative  to 
proceed.  In  such  cases,  although  the  point  of  election  for  the  opening  would 
have  been  by  the  vagina  in  a  woman,  or  by  the  rectum  in  a  man.  the  operator, 


■ 


«« 


J   s 


Fig.  338. — Cullen's  Case.    The  Tip  of  the  Appendix  is  Lost  in  a  Pool  <-e  1'is  Filling  the  Pelvis  and 

\\  axled  in  by  Adherent  Small  Intestine  Everywhere  Covered  bt  Lymph. 

The  intestine  lias  been  lifted  up  ami  the  adhesion  separated  bo  as  toshov  the  abscess.     I  Imrch  Home.     Kemoval 

of  appendix,  drainage.     \V.  P.,  male.  St.  twenty-seven.     June  26,  1902. 


having  advanced  so  far  as  to  open  the  abscess  from  above,  is  obliged  to  proceed 
with  the  evacuation  in  this  direction.  The  closest  attention  must  he  given 
to  protecting  the  surrounding  peritoneum,  while  the  entire  pus  cavity  is 
emptied  and  dried  out.  a  liberal  drainage  orifice  filled  with  loose  gauze 
being  provided,  which  also  fills  the  infected  pelvis. 

The  para-sacral  method  was  clearly  defined  by  Jabottlayui 
189:!  {Rev.  <!<■  chir.,  1S92),  but  it  is  the  very  last  to  be  recommended, 
utiles,   as   in    the   case  of   Berard  and   Patel,  the   collection  of  pus  finds 


PELVIC   APPEXDICAL  ABSCESS.  031 

its  way  back  to  the  sacro-iliac  notch  and  tends  to  open  spontaneously  at  that 
point. 

The  perineal  method,  devised  by  Mauclaire  in  1S95  (Soc.  Anat.,  1897,  p. 
868),  has  been  utilized  by  Delanglade,  who  has  written  an  article  upon  it, 
entitled  " De  I'incision  prerectale  des  absces  pelvienne  iijijiriidiculaire"  (Soc. 
de  ckir.,  Paris.  1(.)(J0,  pp.  bt)(J  et  857).  E.  M.  Sutton,  Lagoutte,  and  especially 
Rotter  have  also  used  the  perineal  method,  the  latter  eleven  times. 

Sutton  (Jour.  Amer  Med.  Assoc,  1898,  vol.  3D.  p.  1438)  reports  the  case  of  a 
locomotive  fireman,  thirty-five  years  old,  in  whom  a  pelvic  abscess  was  watched 
into  the  second  week,  when,  on  account  of  symptoms  of  obstruction,  such  as 
vomiting  and  distention,  it  was  evacuated  through  the  rectum  by  puncturing 
the  anterior  wall  high  up,  with  a  small  trocar,  upon  which  22  ounces  of  pus 
escaped.  After  some  amelioration,  severe  septic  symptoms  followed,  and  the 
abscess  was  found  to  have  refilled.  Tt  was  then  opened  and  drained  through  the 
peritoneum  by  making  a  horseshoe  incision  in  front  of  the  anus,  and  carrying 
the  dissection  carefully  upward  between  the  urethra  and  the  rectum :  the  external 
sphincter  fibres  were  divided,  where  they  interlace  with  the  bulbo-cavernosus : 
the  deep  fascia  also  was  divided,  the  levator  ani  separated,  and  the  prostate, 
when  reached,  was  pushed  forward  as  the  dissection  was  carried  up  to  the  peri- 
toneal cul-de-sac.  On  reaching  this  point,  the  abscess  cavity  was  opened,  and 
nearly  a  quart  of  foul  pus  mixed  with  liquid  feces  escaped,  after  which  a 
drainage-tube  was  inserted.  The  temperature  and  pulse  dropped  to  normal, 
the  bowels  moved  six  hours  after  the  operation,  and  the  intense  suffering 
was  immediately  relieved.  The  drainage-tube  was  removed  on  the  twelfth 
day,  and  the  patient  was  able  to  be  out  of  the  house  in  the  third  week. 

The  method  of  opening  and  draining  the  abscess  by  the  rectum  is  as  follows: 
The  rectum  is  emptied  and  washed  out,  and  when  the  patient  is  well  under  an 
anesthetic,  the  anterior  wall  is  exposed  by  means  of  a  Sims  speculum,  or  by  long 
narrow  retractors.  The  incision  is  then  made  near  the  median  line  and  in  front, 
where  the  vessels  are  least  voluminous,  or  at  a  point  which  has  been  determined 
by  the  finger  as  the  most  prominent  or  the  most  yielding  portion  of  the  inflam- 
matory mass.  The  operator  should  have  previously  determined  by  careful 
bimanual  examination,  with  one  finger  in  the  rectum,  the  exact  location  and 
the  size  of  the  abscess.  The  dilatation  of  the  anus  is  effected  by  the  trac- 
tion instrument  used  to  expose  the  field  of  operation.  In  case  of  doubt  as 
to  the  presence  of  pus  an  aspirating  syringe  may  be  used,  passing  the  needle 
obliquely  through  the  wall  of  the  bowel. 

Berard  and  Patel  advise  a  transverse  incision,  crossing  the  median  line, 
made  with  curved  scissors  under  the  control  of  the  left  index  finger;  the  coats 
of  the  bowel  are  then  cut  through  successively,  and  in  an  oblique  direction, 
proceeding  upward.  As  soon  as  the  abscess  is  opened,  the  orifice  is  en- 
larged by  introducing  the  scissors  and  then  separating  the  blades:   after  the 


632  ABSCESS    IN    NEIGHBORHOOD    OF    APPENDIX 

abscess  has  been  explored  by  means  of  the  finger,  it  can  be  completely 
evacuated  by  pressure  made  softly  from  above.  The  cavity  should  then  be 
gently  washed  oul  until  the  fluid  returns  clear. 

Drainage  ought  never  to  be  omitted,  and  it  is  best  carried  out  by  means 
of  rubber  tubes  a  centimetre  in  diameter.  A  mushroom  tube  of  this  size  is 
readily  retained,  while  the  outer  end  of  it,  lying  on  the  exterior,  conducts  the 
discharges  on  to  a  gauze  pad.  Through  such  a  tube  the  cavity  can  be  washed 
out  from  time  to  time  under  gentle  pressure. 

R.  Peterson  (Amer.  Jour.  Gyn.  end  Obst.,  1000,  vol.  16,  p.  240)  opened 
an  abscess  containing  over  a  gallon  of  foul  pus,  which  pointed  just  within  the 
anus.  On  the  sixth  day  afterward  the  patient  walked  home,  a  distance  of  about 
a  mile  and  a  half,  and  made  a  rapid  recovery. 

In  order  to  avoid  a  reflux  of  stercoral  materials  into  the  abscess  JABOULAY 
recommends  the  following  method,  which  he  has  occasionally  practised:  The 
coats  of  each  lateral  wall  of  the  rectum  are  brought  together  behind  the  drain, 
and  fixed  temporarily  at  the  anus  in  such  a  manner  as  to  form  a  double  canal. 
one  opening  being  in  front  for  drainage,  and  one  behind  for  the  escape  of  fecal 
matter  and  gas. 


CHAPTER  XXVII. 
PERITONITIS. 

PROGRESSIVE  PURULENT  PERITONITIS.     DIFFUSE  PURULENT  PERITONITIS. 

PROGRESSIVE  PURULENT  PERITONITIS. 

When  infection  spreads  beyond  the  bounds  of  the  original  focus  of  the  disease 
in  the  appendix  (see  Fig.  339),  it  may  be  limited,  as  we  have  just  seen,  to  the 
neighborhood  of  the  diseased  organ,  by  a  wall  of  adhesions  agglutinating  the 
adjacent  intestines  and  the  general  peritoneum.  If,  for  any  reason,  however, 
such  as  the  suddenness  of  the  outbreak  finding  the  peritoneum  unprotected 
or  unable  to  defend  itself  on  account  of  the  virulence  of  the  organisms,  the  infec- 
tion is  poured  out  over  a  larger  area  of  the  peritoneal  cavity,  the  resulting  peri- 
tonitis either  becomes  diffuse,  and  even  general  and  universal  as  it  enlarges 
its  boundaries;  or,  on  the  contrary,  it  becomes  encapsulated  here  and  there 
between  the  viscera,  forming  so  many  separate  foci  of  suppuration,  by  which 
the  disease  advances,  establishing  new  foci,  from  point  to  point. 

A  peritonitis  arising  in  this  way,  whether  focal  or  d  i  f  f  use,  possesses 
all  the  characteristics  of  the  original  disease  in  the  right  iliac  fossa,  resembling 
the  lesser  areas  of  infection  in  every  point  except  in  the  extent  of  surface  involved. 
The  profound  shock  and  the  depressing  effect  upon  the  patient  which  charac- 
terize this  form  of  the  affection  are  due  simply  to  the  large  area  involved, 
associated  with  the  absorption  of  toxins  and  pathogenic  bacteria.  In  the  more 
extensive  peritonides  we  observe  such  variations  in  the  character  of  the  in- 
flammatory changes  as  are  indicated  by  the  terms  serous,  f  i  b  r  i  n  o  u  s  , 
purulent,  putrid,  or  h  e  m  orrhagic.  One  or  more  of  these 
forms  may  predominate  in  any  given  case,  or  even  in  different  areas  of  disease 
in  the  same  case. 

One  of  the  most  distinctly  characterized  forms  of  peritonitis  is  the  dis- 
seminated focal,  described  by  Mikulicz  under  the  term  pro- 
gressive fibrino-purulent  (Langenb.  Arch.,  1899,  Bd.  39),  in 
which  the  disease,  running  an  acute  or  a  subacute  course,  advances  by  means 
of  the  peritoneum  to  an  adjacent  area,  where  it  forms  a  fresh  fibrino-purulent 
deposit,  at  first  shut  off  by  adhesions  from  the  remaining  intact  peritoneum; 
it  next  infects  a  fresh  area  through  the  escape  of  pus  between  the  adherent 
coils  of  intestine,  and  starts  up  another  focus  of  deposit,  walled  off  in  its  turn, 

633 


634 


PERITONITIS. 


only  iii  again  advance  to  some  other  point  in  the  aeighborhood,  and  ihns  con- 
tinue its  progress. 

Secondary  abscesses  of  this  description  arc  met  with  he  hind    i  be   ce- 
cum .  in  the  pelvis,  in  the  r  i  g  li  t    renal    region    above    the 


App  atth.  betw. 
Cecum*  parietal  peritcm.  perforation 


Pig.  339.   -Showing  I'i.kforation  nkah  the  Root  <>f  the  Appendix  in  a  Patient  Dying  of  PEnrroNms. 
J.  H.  H.     M.  S.,  tet.  sixty.     Aug  .  Sept  .  1903      Sure.  Path    No.  2181.     The  kink  is  probably  responsible  for  the 

location  of  the  perforation. 


liver,  in  the  right  pie  n  r  a  ,  in  the  left  ilia  c  f  o  s  s  a ,  in  the  1  e  f  t 
r  e  n  a  I  r  e  gi  o  n  .  and  among  the  coils  of  the  intestines.  Jaffe 
speaks  of  cases  in  which  he  found  secondary  abscesses  a  b  o  v  e  a  a  d  t  o  1  h  e 

inside    o  f    the    s  p]  e  e  n  .     A  surgeon  must   hear  in  mind  all  these  seats 


PROGRESSIVE    PURULENT    PERITONITIS.  G35 

of  predilection  in  every  case  in  which  the  opening  of  an  abscess  in  the  neighbor- 
hood of  the  appendix  is  not  followed  by  immediate  improvement.  Only  by 
the  closest  attention  to  all  parts  of  the  abdominal  cavity  and  to  the  pleura,  can  he 
exclude  the  presence  of  one  or  more  of  these  foci  of  secondary  infection,  or  suspect 
and  watch  some  particular  area,  prepared  to  open  and  drain  the  abscess  as  soon 
as  it  is  formed.  The  effect  of  a  concealed,  unopened  abscess  upon  the  general 
condition  of  the  patient  is  so  marked  as  to  be  evident  even  to  the  untutored 
eyes  of  the  family,  anxiously  watching  for  signs  of  improvement.  The  course  of 
the  affection  is  more  protracted  than  that  of  a  diffuse  peritonitis,  and  there  is 
not  the  same  evidence  of  profound  intoxication.  The  fever  is  usually  high,  the 
pulse  is  quickened,  there  may  be  chills,  and  there  is  certainly  restlessness, 
abdominal  discomfort,  tympany,  and  often  pain  in  the  affected  region.  At 
this  juncture  a  careful  palpation  of  the  abdomen,  made  by  little  quick  movements 
of  deep  pressure  with  the  finger-tips  as  they  play  the  gamut  of  the  muscular 
fibres,  will  often  localize  the  affected  area  in  the  right  or  left  lumbar  region. 
The  affected  areas  are  markedly  sensitive,  and  as  the  fluid  accumulates,  resis- 
tance increases,  while  the  area  of  dulness  is  enlarged;  all  this  is  best  revealed 
by  light  percussion.  The  pelvis  must  be  investigated  by  rectal  examination 
in  order  to  discover  any  unusual  tenderness,  boggy  condition,  bulging  or  infil- 
tration of  its  walls.  The  liver  should  be  investigated  by  auscultation  and  per- 
cussion, in  order  to  detect  any  friction  sounds  indicatng  a  peri-hepatitis  or 
any  enlargement  of  the  area  of  dulness,  such  as  would  be  produced  by  an  abscess. 
Any  icteroid  tinge  must  receive  the  closest  attention.  A  bulging  of  the  ribs 
may  indicate  an  empyema. 

Not  only  one,  but  two,  or  even  more  secondary  abscesses  may  form,  neces- 
sitating several  operations.  An  instance  of  this  kind  occurred  in  the  practice 
of  W.  S.  Halsteo,  myself,  and  J.  M.  T.  Finney,  each  of  us  operating  succes- 
sively on  the  same  patient. 

A  nurse,  twenty-five  years  old,  had  a  first  attack  of  acute  appendicitis  with 
typical  symptoms,  for  which  Halsted  operated,  and  found  the  appendix  beginning 
to  lie  gangrenous,  and  partially  separated  from  the  cecum.  There  was  a  small 
post-ceeal  abscess  and  the  pelvis  contained  a  cloudy  fluid.  She  did  well  until  the 
fourth  day,  when  she  complained  of  dull  pain  all  through  the  abdomen  and  down 
the  right  leg.  The  temperature,  which  had  been  nearly  normal,  rose  again,  while 
the  abdomen  became  distended  and  very  tender  in  the  supra-pubic  region.  On  the 
fifth  day  I  made  a  vaginal  opening  behind  the  cervix  uteri,  evacuating  about  200  cc. 
of  foul-smelling  dark  pus.  After  this  there  was  an  immediate  improvement,  but 
on  the  tenth  day  from  the  original  operation  the  patient  complained  once  more  of 
pain  and  chilliness,  the  temperature  again  rose,  and  there  was  slight  nausea.  A 
localized  area  of  moderate  tenderness  was  found  in  the  left  flank,  but  there  was 
no  distinct  tumor  or  fluctuation.  Two  days  later,  that  is  to  say,  on  the  twelfth  day 
after  the  original  operation,  Finney  made  an  incision  in  the  upper  left  inguinal 
region,  evacuating  about  400  cc.  of  pus.     The  opening  into  the  vagina  was  enlarged, 


636  PERITONITIS. 

a  communication  established  between  the  other  two  openings,  and  rubber  drains 
inserted.  The  patient  steadilj  improved,  and  eventually  made  a  perfect  recovery, 
there  being  no  sign  of  hernia  after  several  years. 

Another  series  of  sequences  is  shown  in  a  ease  operated  upon  by  Professor 
Poncet,  the  patient  entering  bis  clinic  in  March,  1892,  with  "  alarming  symp- 
toms of  appendicitis."  This  patient  was  operated  upon  successively  at  several 
days' interval  for  (1)  a  peri-appendical  abscess  in  the  right  iliac  fossa,  (2)  an 
abscess  above  the  liver,  and.  finally.  (3)  a  purulent  pleurisy  (E.  Sallet,  "Des 
dbschs  peri-hepatique,"  Thhse  de  Lyon,  1894). 

Subphrenic  Abscess.  -<  >neof  the  most  important  of  these  secondary  abscesses 
is  that  in  which  the  purulent  deposit  is  situated  above  the  liver  and  below  the 
diaphragm,  in  other  words,  a  subphrenic  abscess  (see  Chap.  X,  p. 
214).  This  form  of  abscess  has  been  well  described  by  ELSBERG,  who  justly 
remarks  that  its  importance  as  a  complication  is  not  sufficiently  recognized. 
He  has  collected  7:!  eases  in  all,  2  of  which  occurred  in  his  own  practice.  His 
treatment  of  the  subject  is  so  satisfactory  that  I  cannot  do  better  than  quote 
his  words  (.1////.  Surg.,  L901,  vol.  :;t,  p.  729): 

"Subphrenic  abscess  processes  secondary  to  disease  of  the  vermiform 
appendix  may  occur  in  one  of  three  ways: 

"  1.  As  a  localization  in  the  right  or  left  subphrenic  region  of  a  general  sys- 
temic infection, — the  infectious  agents  being  carried  to  the  subphrenic  region 
by  the  blood  current.  Here  the  process  is  secondary  to  a  generalized  infection 
and  hence  i<  not  considered  in  this  paper. 

'"_'.  As  a  localized  abscess  formation  in  the  right  or  left  subphrenic  region, 
a  part  of  a  general  purulent  peritonitis  with  foci  of  suppuration  in  various 
parts  of  the  abdominal  cavity.  This  variety  is  infrequent,  as  the  patients 
generally  die  before  encapsulation  of  the  abscess  can  occur. 

"3.  As  a  local  process  by  direct  extension,  or  through  the  lymph  channels 
from  disease  in  or  around  the  vermiform  appendix.  This  is  the  most  frequent 
variety  and  the  one  with  which  this  paper  i<  concerned. 

"According  to  Frankel,  inflammatory  processes  in  the  region  of  the  liver 
may  lie  entirely  within  the  peritoneal  cavity,  or  entirely  outside  of  it.  The 
intra-peritoneal  variety  is  usually  the  result  of  the  direct  extension  of  the  inflam- 
mation from  below.  In  the  extra-peritoneal  variety  the  process  advances  by 
the  retro-peritoneal  route,  behind  the  ascending  colon  and  kidney.  The  abscess 
generally  lies  behind  and  above  the  kidney,  and,  unless  it  is  very  large,  causes 
little  or  no  downward  displacement  of  the  liver.  In  the  73  cases  collected, 
the  abscess  was  extra-peritoneal  in  20  cases  (27  per  cent.),  intra-peritoneal  in 
35  (48  per  cent.),  and  the  anatomic  location  was  doubtful  in  18  cases  (25 
per  cent.). 

"In  the  large  majority  of  patients  the  subphrenic  affection  is  secondary 
to  a  suppurative  inflammation  in  or  around  the  appendix.     Of  the  73  cases 


SUBPHRENIC  ABSCESS.  637 

under  discussion,  there  was  an  abscess  in  or  around  the  appendix  in  50  cases 
(68  per  cent.):  in  the  other  16  no  details  were  given.  When  the  subphrenic 
inflammatory  condition  is  caused  by  direct  extension  from  below,  its  position 
varies  with  the  location  of  the  diseased  appendix.  Of  the  73  cases  the  appen- 
dix lay  behind  the  cecum  of  the  ascending  colon  in  17  patients  (23  per  cent.), 
in  front  of  or  below  the  cecum  or  the  colon  in  12  patients  (1(>  per  cent.),  and 
details  were  wanting  in  44  patients  (61  per  cent.).  In  about  15  per  cent,  of 
the  patients  the  abscess  contained  gas.  Perforation  of  the  diaphragm  oc- 
curred in  25  per  cent,  of  the  cases. 

"The  symptoms  of  subphrenic  inflammation  may  come  on  days,  or  weeks, 
or  months  after  the  disease  of  the  appendix  or  the  operative  measures  instituted 
therefor.     Several  modes  of  onset  are  characteristic. 

"  (a)  A  few  days  after  the  acute  symptoms  of  appendicitis  have  been  relieved, 
and  the  temperature  has  fallen  to  normal,  the  patients  complain  of  pain  in 
the  lower  part  of  the  right  chest,  the  temperature  begins  to  rise,  the  area  of 
liver  dulness  is  somewhat  enlarged,  there  are  friction  sounds  over  the  hepatic 
region,  and  tenderness  in  one  or  two  intercostal  spaces.  There  may  be  slight 
or  well-marked  jaundice.  Within  a  few  days  the  pain  over  the  liver  becomes 
less,  while  the  signs  of  fluid  become  evident. 

"(b)  Before  the  acute  signs  of  appendicitis  have  entirely  subsided,  although 
the  local  symptoms  are  much  improved,  the  daily  temperature  begins  to 
take  on  a  remittent  type,  and  the  patient  begins  to  lose  flesh  and  strength 
rapidly.  These  patients  look  very  ill  from  the  beginning.  They  do  not  com- 
plain of  much  pain,  although  they  may  have  tenderness  in  the  lumbar  region; 
the  most  marked  symptom  is  the  rapid  loss  of  flesh  and  strength.  No  further 
physical  signs  may  be  discoverable  until  the  bulging  of  the  abscess  in  the  lumbar 
region  is  found. 

"  (c)  After  having  recovered  from  the  attack  of  appendicitis  in  a  satisfac- 
tory manner,  some  of  the  patients  never  regain  their  former  health.  Without 
any  change  in  the  temperature,  respiration,  or  pulse,  the  patient  complains 
of  continual  slight  pain  in  the  right  chest.  The  pain  persists  for  weeks  or  months, 
although  physical  examination  and  aspiration  of  the  right  chest  result  negatively. 
These  patients  never  look  very  ill.  After  a  varying  length  of  time,  the  presence 
of  fluid  under  the  diaphragm,  and  perhaps  also  in  the  pleural  cavity,  is  discovered 
by  means  of  physical  examination  and  the  exploring  needle. 

"When  the  subphrenic  abscess  contains  gas,  the  diagnosis  is  generally  more 
easy,  because  of  the  obliteration  of  the  liver  dulness  by  full  tympanitic  res- 
onance ami  because  of  the  presence  of  succussion  sounds.  When  it  does  not 
contain  gas,  the  question  may  arise  whether  one  has  not  to  deal  with  an  effusion 
into  the  right  chest.  Most  of  the  errors  in  diagnosis  that  have  been  made,  have 
been  along  this  line.  Three  conditions  are  possible:  there  may  be  an  effusion 
into  the  pleural  cavity,  or  there  may  be  both  a  subphrenic  and  a  pleural  effusion, 
or  there  may  be  a  subphrenic  effusion  alone.     The  differential  diagnosis  must 


638  PERITONITIS. 

rest  od  the  fact  thai  when  there  Is  a  well-marked  effusion  under  the  diaphragm 

there  are  usually  no  thoracic  symptoms;  the  Upper  level  of  the  dlllness  is  a 
Straight  line  or  is  convex  Upward  ;  there  is  little  change  in  the  line  of  dulness  with 
a  change  in  the  position  of  the  patient.  While  in  a  pleural  effusion  the  respira- 
tory murmur  is  much  diminished  or  absent  below  the  level  of  the  fluid,  in  sub- 
phrenic effusions  the  murmur  can  generally  he  heard   plainly  below  the  level  of 

die  fluid.     Depression  of  the  liver  is  frequent  in  subphrenic  abscesses;  it  is  rare  in 

pleurisy,  unless  the  effusion  is  a  very  large  one.  The  heart  is  never  appreciably 
pushed  to  the  right,  noi'  are  the  intercostal  spaces  bulged  out  in  effusions  under 
the  diaphragm.  If  pus  is  withdrawn  by  aspiration  through  one  of  the  lower 
intercostal  spaces,  and  clear  fluid  by  aspiration  higher  up.  the  diagnosis  of 
an  association  between  the  two  conditions  is  almost  assured.  When  perfor- 
ation of  the  diaphragm  occurs,  it  is  characterized  by  the  sudden  appearance  of 
symptoms  of  invasion  of  the  pleural  cavity, — cough,  rapid  respiration,  expecto- 
ration, and,  frequently,  rapid  collapse. 

"The  differentia]  diagnosis  between  subphrenic  abscess  and  abscess  of  the 
liver  is  often  very  difficult,  and  sometimes  impossible  before  operation.  Abscess 
of  the  liver  is,  however,  much  more  rare  after  appendicitis  than  is  subphrenic 
abscess.  Pain  in  the  right  shoulder-blade  is  rare  in  subphrenic  cases  and  fre- 
quenl  in  abscess  of  t ho  liver.  Paralysis  of  the  diaphragm,  and  hence  dimin- 
ution or  absence  of  respiratory  movements  of  the  liver,  occurs  far  more  often 
in  subphrenic  affections.  Chills  and  profuse  sweats  are  more  frequent  in  abscess 
of  the  liver.  The  final  and  positive  diagnosis  must  be  made  with  the  aspirating 
needle,  the  puncture  being  made  in  the  seventh  to  the  tenth  intercostal  space 
in  the  axillary  line,  unless  there  are  signs  of  pointing  in  front  or  in  the  lumbar 
region.  The  fluid  obtained  by  aspiration  should  be  always  examined  for  liver 
abscess.  The  characteristic  pus  of  liver  abscess  is  of  a  light  chocolate  color 
with  little  or  no  odor.  Foul  odor  of  the  pus  will  generally  mean  subphrenic 
abscess  and  not  liver  abscess,  although  the  possibility  of  an  hepatic  abscess 
which  has  ruptured  into  the  subphrenic  region  must  be  remembered. 
"Of  the  7:!  cases  collected,  the  total  mortality  was  40  per  cent." 
The  method  of  treatment  recommended  by  Elsberg  is  as  follows:  "About, 
two  inches  of  the  ninth  and  tenth  ribs  are  resected  in  the  usual  manner  (Fig.  340), 
somewhere  between  the  scapular  and  the  anterior  axillary  lines,  according  as 
the  exploring  needle  has  located  the  pus  more  anteriorly  or  posteriorly.  The 
two  ribs  can  easily  be  resected  through  one  incision,  made  in  the  intercostal 
space  between  them  (Fig.  341).  After  the  ribs  have  been  resected,  the  diaphragm, 
with  the  liver  showing  below  it,  will  appear  in  the  lowermost  portion  of  the 
wound,  and  the  pleural  reflection  will  be  seen  in  the  upper  part.  If  there  is 
suspicion  that  the  pleural  cavity  contains  pus,  aspiration  of  the  pleura  should 
first  be  done.  If  pus  is  obtained,  the  cavity  should  be  opened  and  drained 
at  once.  If  aspiration  of  the  pleura  is  deemed  unnecessary  or  inexpedient 
(as  is  generally  the  case),  the  upper  part  of  the  wound   should   be   carefully 


OPERATION    FOR    SUBPHRENIC   ABSCESS. 


630 


Fig.  340.  —  Elsberg's  Operation  for  Subphrenic  Ahscess,  Showim;  hie  Skin  Incision.  Two  Inches  in 
Length,  Midway  between  the  Anterior  Axillary  and  Scapular  Lines  between  hie  Ninth  and 
Tenth  Ribs. 


(ill) 


PERITONITIS. 


protected  with  gauze,  and  the  aspirating  needle  then  made  to  perforate  t ho 
diaphragm  below  the  reflection  of  the  pleura  (Fig.  342).  [f  the  needle  enters 
the  abscess  cavity,  it  should  be  allowed  to  remain  in  place  and  be  used  as  a 
director.  A  small  incision  of  the  diaphragm  alongside  of  the  needle,  the  dilatation 
of  the  small  opening  with  the  dressing  forceps,  and  the  drainage  of  the  abscess 
cavity  with  tubes,  according  to  general  principles,  are  all  thai  is  required.    The 


Fig.  341. — Resection  of  About  two  Inches  of  Ninth  and  Tenth  Ribs. 
The  pleural  reflection  is  seen  below  the  costo-pbrenic  sinus  of  the  pleura.     Below  this  lies  the  diaphragm 
covering  the  abscess.     The  figure  to  the  ri^ht  shows  :i  coronal  section  of  the  body  revealing  the  pleural  retlcction 
with  the  costo-phrcnic  sinus  above  and  with  the  diaphragm  below. 


abscess  cavity  may,  however,  be  situated  so  near  the  median  line,  high  up  under 
the  dome  of  the  diaphragm,  that  it  can  only  be  reached  by  the  transpleural 
route.  The  pleural  cavity  can  then  be  opened  without  further  delay  through 
the  upper  part  of  the  wound.  In  some  cases  the  costo-phrenic  sinus  has  been 
entirely  obliterated  by  adhesive  inflammation,  so  that  the  pleura  can  be  incised 
without  opening  the  pleural  cavity  proper.  If  this  is  the  case,  great  care  must 
be  taken  not  to  tear  the  adhesions,  as  they  are  often  very  weak  and  easily  sep- 


DIFFUSE    PURULENT    PERITONITIS. 


641 


arated.  If  the  pleural  cavity  must,  nevertheless,  be  opened,  it  should  be  dene 
as  rapidly  as  possible.  By  means  of  upward  pressure  against  the  liver,  it  is 
often  possible  to  so  closely  approximate  the  diaphragmatic  to  the  costal  pleura 


Fig.  :442. — Aspirating  the  Abscess  through  the  Diaphragm  ani>  below  the  Pleural  Reflection. 
The  operation  may  be  transpleural  if  necessary,  when  there  is  fluid  in  the  pleura  as  well.     The  aspirator  indi- 
cates the  position  of  the  abscess,  which  is  then  evacuated  and  drained  through  a  free  incision. 

that  little,  if  any,  air  can  enter  the  pleural  cavity  when  the  opening  is  made. 
Sometimes  it  is  impossible  to  unite  the  two  pleural  layers  by  suture,  and  all 
that  can  be  done  is  to  wall  off  the  cavity  carefully  with  antiseptic  gauze.  " 


DIFFUSE  PURULENT  PERITONITIS. 

A  diffuse  peritonitis  is  one  in  which  the  exact  limits  cannot  be  deter- 
mined in  vivo.  The  entire  area  accessible  to  the  eye  is  more  or  less  involved, 
the  infectious  material  being  distributed  over  a  large  extent,  and  tending,  unless 
checked,  to  a  rapid  involvement  of  the  entire  peritoneum.  The  statement 
that  a  peritonitis  is  "general"  or  "universal"  can  hardly  be  made  without 
41 


642  i'i  WTONins. 

such  a  painstaking  investigation  of  every  portion  of  the  abdomen  as  is  unjusti- 
fiable in  the  course  of  an  operation.  A  diffuse  peritonitis  of  this 
kind  is  so  called,  in  contrast  to  the  c  i  r  c  u  m  s  <•  r  i  l>  e  d  p  e  r  i  t  o  n  i  t  i  s 
limited  to  the  righl  iliac  fossa,  and  the  d  iss  e  m  ina  <  e  d  E  o  <•  a  1  ]>  e  r  i  - 
t  i)  n  i  t  i  s  involving  particular  areas  and  shut  off  from  the  rest  of  the  cavity 
by  limiting  adhesions.  A  large  abscess  occupying  the  entire  lower  abdomen, 
and  sometimes  containing  quarts  of  pus  (which  is  oftenest  found  in  children), 
is,  nevertheless,  circumscribed  in  character.  A  diffuse  peritonitis, 
on  the  other  hand,  may  go  on  to  the  formation  of  an  abscess  filling  the 
entire  abdomen  and  resulting  in  abdominal  empyema.  There  is  a  Btrong 
temptation  to  speak  of  a  case  as  one  of  "general  peritonitis"  when  (he  in- 
testines of  the  lower  abdomen,  as  far  as  seen,  are  found  inflamed  and  covered 
with  deposits  of  pus  in  both  flanks  as  well  as  in  the  pelvis.  VoN  BuRCKHARDT 
proposes  to  use  the  term  "progressi  ve"  in  place  of  the  vague  expres- 
sion   "d  i  f  f  us  e  ." 

A  g  e  n  e  r  a  1  ,  or  perhaps  more  correctly,  a  tidal  peritonitis,  is 
one  in  \v  h  i  c  h  t  h  e  e  n  t  i  r  e  a  hd  o  in  ina]  c  a  v  i  t  y  is  in- 
volved, including  the  structures  above  the  omentum  and  the  colon, espe- 
cially in  the  diaphragmatic  regions,  as  well  as  those  helow.  The  most  acute  form 
of  diffuse  peritonitis  is  appropriately  termed  peritoneal  sepsis  (Wit- 
zel,  "Diffuse  citrine  Peritonitis  und  peritoneale  Sepsis,"  Dtsch.  med.  Woch., 
1SSS,  No.  ID);  it  being  one  in  which  the  patient  dies  with  an  acute  intoxica- 
tion so  soon  after  the  onset  of  the  disease  that  little  or  no  reactive  signs  are  found 
in  the  peritoneum.  There  is  only  a  slight  injection,  perhaps  a  little  loss  of 
lustre,  and  a  little  fibrin,  some  bloody  serous  exudate,  and,  most  important 
of  all,  n  o  adhesions  setting  u  p  a  1>  a  r  r  i  e  r  for  t  h  e  1  i  in  - 
L  t  a t i  on     "f     t  h  e    disease. 

A  d  i  f  f  u  s  e  p  u  r  u  1  e  n  t  peritonitis  is  occasioned  by  an  infection 
of  lesser  intensity  existing  for  a  longer  time;  where  nature  has  been  able,  more  or 
less  successfully,  to  combat  (lie  infection,  pus  is  found  widely  distributed, 
particularly  in  dependent  regions;  the  intestines  are  everywhere  deeply 
injected,  and  in  place  of  the  normal  lustrous  coat  a  shaggy  surface  is  seen 
covered  with  little  bits  of  fibrin,  often  with  a  capillary  vascularization,  which 
float  out  underwater,  the  coils  of  intestines  are  mutually  adherent,  and  then- 
is  an  abundant    fibrinous   and   fibrino-purulent  deposit. 

Diagnosis. — The  diagnosis  of  a  diffuse  peritonitis  is  made  by  giving  close 
attention  to  the  general  character  of  the  abdominal  pain  and  the  marked  tender- 
ness on  pressure.  The  abdomen  is,  as  a  rule,  tympanitic,  the  tympany  being  a 
conservative  effort  on  the  part  of  nature  to  limit  the  spread  of  the  infection. 
Once  in  a  while,  however,  an  extensive  peritonitis  is  found  in  a  scaphoid  abdo- 
men. The  fever  is  often  marked,  though  sometimes  quite  wanting.  The 
pulse  is  small  ami  shows  an  increased  rapidity,  often  going  up  to  120,  140, 
and  even  higher,  although  where  the  infection  is  not  so  severe  in  character, 


DIFFUSE    PURULENT    PERITONITIS.  043 

the  pulse-rate  may  remain  nearly  normal.  One  of  the  most  important  signs 
is  the  persistent,  distressing  nausea  and  vomiting  which  generally  characterize 
the  affection  from  first  to  last,  although  they  sometimes  cease  toward  the  end, 
the  cessation  producing  an  illusory  impression  of  improvement.  A  further 
most  important  sign,  which  is  associated  with  the  cessation  of  peristalsis,  is 
the  cessation  of  fecal  movement  and  the  passage  of  gas.  The  distended 
abdomen  is  fixed,  and  the  respiration  becomes  superior  thoracic  in  type. 
There  is  often  a  dry,  typhoid  tongue,  and  later  on  a  mild  or  marked  delirium. 
As  the  infection  spreads  the  system  becomes  dried  out  for  want  of  water 
and  the  excretion  of  urine  is  much  diminished.  There  is  sometimes  an  accumu- 
lation of  ascitic  fluid.  One  of  the  most  marked  signs  in  advanced  cases  is  the 
facial  expression,  which  is  distressed  and  anxious,  the  patient  having  a  collapsed 
look,  with  hollow  eyes  and  a  dusky  skin,  the  expression  alone  being  often 
sufficient  to  indicate  the  nature  of  the  malady  to  an  experienced  eye.  V.  H. 
Williams  graphically  says  of  one  of  his  cases:  "He  had  that  gray,  hard,  sal- 
low, anxious  look  of  sepsis,  which  means  much  to  the  eye  of  the  surgeon" 
(Trans.  Amer.  Surg.,  1893,  p.  2G1). 

The  first  step  in  the  differential  diagnosis  is  to  distinguish  between  these 
cases  of  diffuse  peritonitis  and  cases  of  a  circumscribed  abscess  still  limited 
to  the  neighborhood  of  the  appendix,  in  which  the  local  inflammation  has  called 
forth  a  marked  reactive  disturbance  of  the  entire  peritoneum.  In  a  localized 
peritonitis  there  may  be  fever,  quickened  pulse,  vomiting,  and  a  general  tym- 
pany of  the  abdomen,  associated  with  more  or  less  general  discomfort.  A  care- 
ful examination,  however,  will  usually  show  that  the  tenderness  is  pretty  well 
localized,  and  that  there  is  a  well-defined  mass  shut  off  in  the  iliac  fossa. 
Furthermore,  the  effect  on  the  general  condition  of  the  patient  is  not  that  of 
the  profound  depression  associated  with  the  more  extensive  disease.  It  is  in  just 
these  cases,  however,  in  which  a  local  affection  is  passing  into  a  general  one,  that 
the  most  serious  mistakes  are  made,  and,  where  there  is  doubt,  it  is  better  to 
operate  than  to  wait  for  the  extension  of  the  disease. 

The  differential  diagnosis  between  intestinal  obstruction  and 
peritonitis  accompanied  with  tympany,  nausea,  and  pain,  is  sometimes  even 
more  difficult.  In  intestinal  obstruction,  however,  fever,  at  first,  is  lacking, 
there  is  no  such  widespread  sensitiveness  to  pain  as  in  peritonitis,  and  the 
distention  is  limited  to  the  loops  of  intestine  which  lie  near  to  the  obstruction. 
These  loops  can  often  be  seen  and  felt  as  they  contract,  and  roll  their  gaseous 
contents  under  the  fingers  in  the  effort  to  force  a  passage  through  the  barrier, 
the  pain  being  associated  with  the  attacks  of  peristalsis.  Moreover,  in  intestinal 
obstruction  there  is  no  increasing  leucocytosis.  In  either  case  relief  is  to  be 
sought  in  operative  measures. 

Prognosis. — The  prognosis  in  cases  of  diffuse  peritonitis  depends  upon 
the  character  of  the  infection,  as  well  as  upon  its  extent.  Where  it  has  spread 
very  rapidly,  and   there  is  a  profound  depression,   as  in  cases  of  peritoneal 


644 


PERITONITIS. 


sepsis,  there  is  scarcely  any  hope,  whatever  may  be  done.  In  all  cases  the 
prognosis  is  serious,  but  in  those  which  tend  to  run  a  protracted  course  with 
decided  local  reaction  against  the  infection,  there  is  a  chance  with  operation 
and  none  without   it.     The  reaction  of    the  leucocytes  should   lie  studied,    the 

blood  should  he  examined,  and  cultures  taken,  to  ascertain  if  there  is  any 
marked  septicemia.  As  soon  as  pus  is  reached  in  the  course  of  the  operation, 
it  should  he  examined  microscopically;  if  streptococci  are  found  the 
prognosis  is  far  more  serious  than  in  a  more  extensive  colon  bacillus 
infection  even  though  the  disease  is  limited  in  its  area.  Cultures  should  also 
he  made  for  examination  throughout  convalescence. 

Treatment  in  General. — Where  it   is  not   possible  to  operate    immediately, 
the  first  step  in  the  treatment  of  a  diffuse  peritonitis  is  to  put   the  patient  as 


Fig.  343. — Fowler's  Method  of  Drainage. 
The  thorax  is  elevated  to  cause  the  fluids  to  gravitate  into  the  pelvis  instead  of  upward  toward  the  diaphragm. 


nearly  as  possible  in  a  condition  of  absolute  repose.  He  should  lie  on  his  back 
with  his  head  on  a  low  pillow,  and  his  knees  drawn  up  and  supported  by  a  round 
cushion,  so  perfectly  at  rest  that  he  appears  as  if  fused  with  the  bed.  Any 
movement  for  the  purpose  of  giving  necessary  attention,  such  as  the  use  of 
the  bed  pan.  bathing,  alcohol  rubbing,  etc.,  should  only  be  made  with  the  utmost 
care.  The  bowels  are  best  kept  at  rest  ("in  splints")  by  the  administration  of 
opium  in  small  quantities;  this  relieves  the  pain  and  checks  peristalsis,  thus 
favoring  the  formation  of  adhesions  and  limiting  the  spread  of  infection.  If  the 
bowels  are  much  distended,  morphine,  as  KoRTE  says,  is  better  than  opium. 

A  decided  elevation  of  the  head  of  the  bed  is  advisable  (see  Fig.  343).  if 
not  disagreeable  to  the  patient,  as  it  may  limit  the  spread  of  the  infection 
upward  into  the  most  unfavorable  part  of  the  abdomen,  and  determine  its 
gravitation    toward  the    pelvis,  where  it  can  be  better  drained.      The  patient 


DIFFUSE    PURULENT    PERITONITIS.  G4o 

will  be  more  comfortable  if  the  bedclothes  arc  kept  off  the  body,  but  if  tin- 
abdominal  walls  are  thin,  hot  poultices,  which  dilate  the  capillaries  and  thus 
facilitate  the  elimination  of  the  infectious  products,  may  give  comfort  and 
also  be  of  service  in  limiting  the  infection.  Ice  poultices,  if  better  borne, 
may  check  the  growth  of  the  bacteria. 

Where  there  is  much  vomiting,  the  washing  out  of  the  stomach,  which  for 
many  years  has  been  tried  and  found  of  the  utmost  service  by  KusSMAUL  and 
others,  often  affords  the  greatest  relief.  It  should  be  done  with  a  soft  rubber 
tube,  and  even  though  attended  with  considerable  discomfort  to  the  patient, 
should  not  be  neglected.  As  a  general  rule,  it  is  best  to  give  no  food  or  drink, 
using  the  rectum  as  an  avenue  of  alimentation  by  injecting  about  100  cc.  of 
albumen  water  or  pancreatized  milk  at  intervals  of  six  hours.  It  also  relieves 
thirst,  besides  improving  the  pulse  and  general  condition  of  the  patient,  to 
give  from  100  to  1000  cc.  of  a  normal  salt  solution  twice  a  day.  as  recommended 
by  LENNANDER,  and  widely  practised  by  American  surgeons  for  some  years 
past.  Sometimes  it  is  necessary  to  accede  to  the  urgent  entreaties  of  the 
patient  and  give  a  little  cracked  ice  or  a  teaspoonful  of  hot  or  cold  water, 
or,  asKoRTE  advises,  a  carbonated  water.  If  water  is  given  by  the  mouth, 
the  occasion  may  be  utilized  by  administering  a  little  albumen  with  it.  If  an 
operation  is  to  take  place  within  an  hour  or  two,  and  the  bowels  are  loaded,  a 
warm  saline  enema  may  be  given  in  order  to  evacuate  the  rectum. 

Surgical  Treatment. — It  is  important  in  surgical  treatment  to  observe 
the  following  rules: 

1.  To  make  the  operation  as  brief  as  possible,  consistent  with  thorough 
technic. 

2.  To  watch  the  patient  closely,  and  keep  up  the  vitality  during  the  oper- 
ation. 

3.  To  remove  all  septic  products  as  quickly  and  as  completely  as  possible. 

4.  To  extirpate  or  to  wall  off  the  original  focus  of  the  infection,  the  appendix. 
.").  To  provide  abundant  avenues  for  the  escape  of  any  further  septic  material 

which  may  accumulate. 

6.  To  relieve  excessive  tympany. 

If  the  pulse  is  small,  the  heart  weak,  and  the  patient  collapsed,  it  is  well 
to  begin  the  operation  by  injecting  from  500  to  1000  cc.  of  normal  salt  solution 
as  the  patient  goes  on  the  table,  the  injection  continuing  during  the  operation. 
Hypodermics  of  strychnine  help  to  keep  up  the  strength  and  to  tide  the  patient 
over  the  shock  of  the  operation.  They  may  be  begun  with  one-thirtieth  of  a 
grain,  and  continued  with  one-sixtieth,  every  two  hours,  until  a  good  reaction 
is  established,  and  then  be  kept  up  at  intervals  of  every  three  or  four  hours  for 
several  days,  unless  there  are  signs  of  the  physiologic  action  of  the  drug. 

As  a  preventative  againsl  shock,  all  unnecessary  exposure  of  the  body  must 
be  avoided,  the  patient  should  lie  kept  wrapped  in  blankets  while  on  the  oper- 
ating table,  and  hot  flasks  covered  with  flannel  should  be  placed  under  the  arm- 


646 


PERITONITIS. 


pits,  a1  the  sides  of  the  chest,  and  by  the  legs.  Whenever  hoi  bottles  are 
used  either  on  the  operating  table  or  in  the  bed,  they  should  be  closely 
watched  to  avoid  a  burn. 

All  preparations  must  be  made  before  the  anesthetic  is  given;  it  is  best  to 
begin  the  anesthesia  with  nitrous  oxide  gas  followed  with  ether. 

The  Incision.— If  the  abdomen  is  small  and  the  walls  flaccid,  it  is 
a  good  plan  to  make  a  liberal  incision  in  the  righl  semilunar  line.  Where  the 
affection  is  advanced,  and  all  parts  of  the  abdomen  seem  uniformly  involved, 
an  incision  in  the  linea  alba  from  the  umbilicus  to  the  symphysis  affords  a  still 


Fir,.  344. — Self-retaining  Retractor. 
Saves  an  assistant  by  holding  the  abdominal  walls  widely  apart  while  the  abdominal  cavity  is  being  cleansed  in 

general  peritonitis.     (One-half  natural  size.)  . 


better  opportunity  for  examining  all  parts  of  the  abdomen,  for  cleansing  the 
peritoneum,  and  for  making  counter-openings  for  drainage.  Good  broad  retrac- 
tors are  nf  service  in  exposing  one  part  of  the  abdomen  after  another.  The 
practitioner  who  has  not  the  advantages  of  a  hospital  clinic  and  well-trained 
assistants,  will  often  find  a  self-retaining  retractor  (Fig.  344),  which  gives  a 
maximum  exposure  of  the  abdomen  through  the  wound,  of  great  service  while 
he  is  mopping  out  or  irrigating  the  abdomen. 

J.  Israel  (Verlmndl.  d.  dtsch.  GeseU.  j.  C'hir.,  26th  Congress,  Berlin,  1S97,  p. 
l.'ii  says  that  as  it  is  impossible  to  empty  a  generally  infected  abdomen  completely 
of  its  purulent  exudate,  he  has  been   in  the  habit  for  some  years,  in  order  to 


DIFFUSE    PURULENT    PERITONITIS.  (147 

limit  the  harm  dune  by  the  remaining  infectious  masses,  of  making  an  exten- 
sive transverse  incision  of  the  abdominal  wall  (Kreuzschnitt)  in  such  a  manner 
as  to  do  away  with  intra-abdominal  pressure,  and  in  this  way  hinder  the  absorp- 
tion of  fluid.  He  does  this  by  making  the  aforesaid  transverse  incision,  dividing 
both  recti,  and  then,  after  thoroughly  drying  out  all  accumulations  of  purulent 
material,  leaving  the  abdomen  open.  In  order  to  prevent  any  prolapse  of  the 
intestines  the  deficiency  in  the  abdominal  wall  is  replaced  by  an  extensive  iodo- 
form gauze  apron,  the  corners  of  which  are  thrust  under  the  edges  of  the  wall. 
This  treatment  insures  free  drainage  from  the  abdomen,  yet  the  intestines  do 
not  escape,  and  the  large  wound  begins  to  contract  surprisingly  soon.  Israel 
has  secured  much  better  results  from  it  in  bad  cases  of  general  peritonitis, 
than  those  he  formerly  obtained. 

Lifting  out  the  Intestines. — "With  the  great  irregularities 
ami  the  numerous  recesses  of  the  abdominal  cavities  in  mind,  it  is  a  strong 
temptation  to  the  surgeon,  in  his  desire  to  get  rid  of  all  the  infection,  to  lift 
out  the  intestines  and  to  expose  and  cleanse  them, as  well  as  the  emptied  abdomen. 
This  plan  has  been  faithfully  tested  by  some  of  our  best  surgeons,  notably  Finney 
(Johns  Hopkins  Hospital  Bull.,  1897,  vol.  8,  pp.  141  and  143)  in  a  series  of  experi- 
ments upon  dogs,  which  showed  a  remarkable  number  of  recoveries  under  this 
treatment.  He  therefore  advocated  the  removal  of  the  intestines,  which  were 
wrapped  in  warm  towels;  the  peritoneal  cavity  was  then  thoroughly  washed 
out  with  hot  salt  solution,  and  dried  with  strips  of  gauze,  after  which  the  intes- 
tines were  cleaned,  loop  by  loop,  under  a  continuous  irrigation  with  salt  solution, 
and  finally  returned  to  the  abdominal  cavity  and  the  incision  closed,  a  small 
opening  being  left  for  drainage.  McCosh  (Ann.  Sun/.,  1897,  vol.  26,  pp.  17'.) 
and  6S7)  also  recommends  removal  of  the  intestines,  associating  this  in  suitable 
cases  with  incision  of  the  ileum  to  evacuate  gas  and  feces,  and  with  the  injection 
of  magnesium  sulphate  into  the  intestine,  followed  by  closure  of  the  intestines 
and  then  of  the  abdomen.  Experience,  however,  has  demonstrated  that  it  is 
better  to  refrain  from  taking  out  the  intestines  on  account  of  the  profound 
shock  which  rapidly  supervenes. 

Irrigatio  n  . — It  is  still  a  moot  point  whether  or  not  it  is  best  to  irrigate 
the  peritoneum.  When  it  is  easily  inspected,  and  accumulations  of  septic 
materials  are  seen  in  all  parts,  irrigation  may  be  carried  out  with  a  hot 
normal  salt  solution  at  a  temperature  between  105°  and  110°  F..  using  such  an 
instrument  as  that  shown  in  Fig.  345.  The  fluid  is  allowed  to  accumulate 
in  considerable  amount,  first  in  one  part  and  then  in  another,  and  then,  the 
edges  of  the  incision  being  raised,  to  escape  with  a  rush,  bringing  away 
quantities  of  septic  material.  After  washing  out  in  this  way,  the  abdominal 
wall  may  be  pushed  forward,  first  in  the  right,  and  then  in  the  left  flank,  and 
rapidly  incised,  for  the  insertion  of  a  large  rubber  drainage-tube  in  the  posi- 
tion for  natural  drainage  (Fig.  34G).  The  various  positions  for  drainage  are 
shown    in    the    composite    picture,   Fig.  347,  which   also    indicates    the    areas 


Ki-i.  345.     Showing  Method  <>»  Washing  <"  r  rai  Abdomen  wh>m  ir 
u  i  '  i.i.  01  Pea  bt  Means  >,k  ihj.  Long  Mm*i.   l«  be  with  Spray 

ATTA'  HMEN  I. 

The  abdominal  wall  i-  lifted  by  means  of  the  retractor  t<.  facilitate 
i  the  Quid.     Thu  plan  i~  »<»  he  followed  only  when 
there  is  widespread  suppuration;  under  other  conditions  it  would  only 
■  o    oread  thi 


648 


DIFFISK    PIIU'LKXT    PF.IUTOXITIS. 


049 


controlled  by  the  drains.  It  is  best  not  to  use  any  strongly  medicated  solu- 
tions in  washing  out  the  peritoneum,  such  as  corrosive  sublimate,  advised  by 
Lttcke  (Dtsch.  Zeitschr.  /.  Chir.,  1887,  Bd.  26)  and  Mortox  (Jour.  Ann,-.  Med. 
Assoc.  ISSN,  vol.  10,  p.  75),  or  salicylic  acid,  as  recommended  by  Steinhal 
(Verhandl.  d.  dtsch.  GeseUsch.  /'.  Chir.,  1888,  Bd.  2,  p.  243). 

The  appendix,  the  Jons  et  origo  mali,  should  be  clamped  off  and  removed 
whenever  it  is  possible.  If  the  tissues  about  the  organ  are  gangrenous,  and 
there  is  little  hope  of  the  sutures  holding,  the  entire  area  surrounding  the  head 
of  the  cecum  must  be  walled  off  from  the  rest  of  the  abdominal  cavity,  and 


Fig.  346. — Method  of  Using  the  Irrigator  to  pl-sh  forward  the  Peritoneum  in  the  Abdominal  Wall 
in   .Making  a  Left  Lumbar   Inczsxon  for  Drainage  in    Case  of  Abdominal  Pyemia. 

drained  separately  through  a  liberal  incision  made  at  the  nearest  point  in  the 
abdominal  wall. 

Some  successful  and  interesting  efforts  have  been  made  to  save  life  by 
continuous  irrigation  of  the  abdominal  cavity;  for  example,  E.  Laplace 
(Phila.  Med.  Jour..  Oct.  14.  1899)  reports  ".1  case  of  acute  /intend  peritonitis 
treated  by  continuous  irrigation  with  normal  suit  solution." 


The  patient  had  a  disseminated  fibrino-purulent  peritonitis  with  a  gangrenous 

omentum.     After  a    thorough   cleansing,   lasting   for  forty-five   minutes.    Laplace, 
who  had  never  seen  so  grave  a  case  recover,  adopted  the  following  plan:   the  glass 


650 


PER]  rONITIS. 


nozzle  of  the  irrigator,  still  attached  to  its  rubber  tube,  was  introducea  as  '     as 
Douglas'  cul-de-sac,  and  the  tube  fixed  to  the  abdominal  wall  l>y  means     '  a  sutur 
at  the  lower  end  of  the  incision.     An  ordinary  glass  tube  with  rubber  tubing  at t; 
was  inserted  at  a  point  A  inches  above  this.     The  rest  of  the  incision,  above 
second  tube  was  closed,  while  the  wound  between  the  first  and  second  tubes  \ 


r.  lumb 


dl  ;>x  ^ 

^  median.     } 

1 1     i 

/      ■•'.-■■■  v. 


*t' 


. 


im  bar 


/y//wk 


3'»; 


347.     Showing  Direction  of  Current  from  ink  Adjacent  Portions  of  the  Abdominal  Cavity  toward 
in    Drainage  Openings  in  the  Right  Iliac  1'ossa,  in  the  Right  and  Left  Lumbar  ReoxonSi  in  thf. 
Median  Line,  and  through  the  Vagina.     It  is  only  in  Exceptional  Cases  that  more  than  one  Open- 
ing is  made.     '  Sep  p.  648 


packed.  A  small  gauze  dressing  was  loosely  laid  on  the  wound  and  held  in  place 
by  adhesive  plaster.  The  patient  was  then  placed  on  a  Kelly  drainage  pad,  com- 
municating with  a  bucket  under  the  bed.  An  irrigator  was  attached  to  the  first 
tube  and  a  warm  normal  salt  solution  was  allowed  to  flow  continuously  through 
the  abdominal  cavity,  draining  through  the  second  tube  and  out  through  the  wound 
on  to  the  pad.  and  thence  into  the  bucket.     This  irrigation  was  kept  up  continu- 


DIFFUSE    PURULENT    PERITONITIS.  651 

ousi      da;    and  night,  for  seventy-two  hours  from  the  time  of  operation,  at  the 

te  of  10    »ints  every  fifteen  minutes,  making  a  total  flow  of  360  gallons  of  normal 

ilution  through  the  abdomen  in  that  time.     One-fortieth  of  a  grain  of  strych- 

sulphate  was  given  every  three  hours.     At  the  end  of  the  seventy-two  hour-. 

•m  the  irrigation  was  discontinued,  the  patient's  condition  was  good,  the  tem- 

rature  9'1°  F.,  and  the  pulse-rate  70. 

A  year  later  Van  Lexxep  reported  a  similar  case  (Hahn.  Med.  Month.,  Feb., 
100),  the  treatment  in  it  having  been  suggested  by  the  report  of  Laplace. 

The  patient,  a  man  of  twenty-four,  had  had  several  attacks  of  appendicitis,  and 
peration  was  performed  at  the  end  of  twenty-two  hours  from  the  beginning  of  the 
t  one,  his  condition  being  then  very  bad.     The  pelvis  and  abdomen  contained 
;ts,  if  not  quarts,  of  thin,  offensive,  sero-purulent  fluid.     The  appendix  was  re- 
moved and  a  glass  ovariotomy  tube,  inverted,  and  with  the  perforated  end  covered 
by  rubber  drainage  tubing,  was  inserted  through  the  lower  angle  of  the  wound  into 
the  bottom  of  the  pelvis.     Another  bent  glass  tube,  "  right  end  up,"  was  placed  under 
*    •  liver  and  connected  with  a  rubber  tube  leading  into  a  tub  beside  the  bed.     The 
n,.  Tmedia    •  peritoneal  layers  were  closely  sutured  and  the  closure  tested  by  liberal 
irrigation  1>  fore  the  patient  was  removed  from  the  operating  table.     The  remainder 
of  the  wc       I  was  left  open.     Continuous  irrigation  was  kept  up  for  about  twelve 
hours.  •  20  gallons  of  sterilized  normal  salt  solution  being  passed  into  and  out 

of  the  peritoneal  cavity  during  that  time.     It  was  then  deemed  advisable  to  stop 
on  account  of  dyspnea  and  rapid  respiration.     Recovery  followed. 

Another  form  of  treatment  which  calls  for  mention  in  connection  with  that 
of  continuous  irrigation,  is  that  of  injection  of  alcohol  directly  into  the  ab- 
dominal cavity,  successfully  practised  by  Z.  E.  Evans,  of  Travers  City,  Mich. 
(Ann.  Gyn.  and  Peel,  1893,  p.  744). 

The  patient,  a  physician,  thirty-three  years  old,  had  had  five  previous  attacks 
of  appendicitis.  When  operation  was  performed,  his  temperature  was  over  103°  F., 
his  pulse  140,  and  the  abdomen  distended  to  its  utmost  capacity.  The  abdominal 
cavity  was  opened  by  a  five-inch  incision.  It  was  found  ruptured,  and  its  contents 
distributed  freely  over  the  general  peritoneal  cavity.  The  appendix  was  gan- 
grenous, detached,  and  floating  in  feces.  In  spite  of  the  extremely  low  and  un- 
promising condition  of  the  patient.  Evans  took  time  to  wash  out  the  abdominal 
cavity  with  warm  water,  and,  to  use  his  own  words.  "  with  one  hand  in  the  abdomen, 
I  paddled  the  water  around  among  the  various  coils  of  the  intestines,  washing  them 
absolutely  clean."  The  abdominal  cavity  was  then  filled  with  warm  water,  and 
about  three  yards  of  gauze  were  introduced  deep  down  into  the  pelvic  cavity  and 
spread  about  among  the  intestines.  A  suture  was  passed  at  each  angle  of  the 
wound,  and  "the  patient  placed  in  bed.  more  dead  than  alive."  The  next  day,  as 
his  pulse  and  temperature  were  still  up,  and  his  mouth  and  skin  dry,  the  drainage 
gatize  was  removed  and  the  abdomen  again  filled  with  warm  water  with  immediate 
good  effect,  made  apparent  in  a  sleep  lasting  five  hours.     On  the  third  day  he  began 


652  PERITONITIS. 

tn  cough  and  to  bring  up  a  "thick  pus-like  substance  mixed  with  I>1 1";   at  the 

same  time  In-  complained  of  a  fixed  pain  in  the  righl  side.  The  base  of  the  right 
lung  was  found  to  be  pneumonic,  and  as  the  stomach  was  rebellious  and  the  sphincters 
relaxed,  Evans  then  threw  a  stimulant  into  the  abdominal  cavity,  injecting  by  means 
of  a  Davidson  syringe,  3  nun  its  of  pure  alcohol  diluted  with  2  quarts  of  warm  water. 
Following  this  treatment,  the  pulse  dropped  from  1  Id  to  K>7.  and  the  temperature, 
which  was  over  103°,  to  aboul  100°  F.     About  eighteen  hours  later  the  same  process 

of  Stimulation  was  repeated,  and  five  hours  alter  it  the  pulse  was  92,  the  temperature 
99  I'.,  the  respiration  '2'2,  the  skin  moist,  the  stomach  quiet,  and  the  sphincters 
contracted  so  that  urine  or  feces  were  no  longer  passed  in  bed.  At  the  end  of  five 
weeks  from  the  day  of  operation  the  patient  had  so  far  recovered  that  he  was  aide 
to  go  to  his  office  ami  attend  to  his  professional  duties.  In  a  personal  communica- 
tion, Dr.  Evans  states  that  he  was  in  good  health  in  February,  1902. 

Delbet  ("  Recherches  exp&rimentales  sur  le  lavage  du  peritoine,"  Ann.  de 
ijyncc,  1SS0,  torn.  .'!!',  p.  1(>.">)  has  shown  that  after  irrigation  for  ten  minutes, 
the  absorptive  powers  of  the  peritoneum  are  so  reduced  that  it  is  possible  to 
follow  the  irrigation  with  a  poisonous  solution  without  harm  to  the  animal. 

W  i  pin  g  o  it  t  the  [n  tes  t  i  n  e  s  . — The  majority  of  surgeons  to-day 
prefer  to  attack  an  extensive  peritonitis  by  what  may  he  called,  in  contrast  with 
the  method  jusl  described,  the  dry  plan  of  treatment;  that  is  to 
say,  the  abdomen  is  opened,  the  .areas  of  accumulation  of  septic  material,  when 
there  are  such,  are  exposed,  and  this  material  wiped  off  as  far  as  possible  with 
gauze  or  sponges.  The  advantage  of  this  plan  is  that  there  is  no  danger  of 
carrying  septic  materials  into  corners  where  they  have  not  been  before,  and 
lodging  them  there.  No  one,  perhaps,  is  more  emphatically  opposed  to  irriga- 
tion than  Reichel,  who  has  expressed  himself  in  the  oft-cited  dictum  that  "die 
Spiih  ri  i  ih  r  l'i  ritonealhohle  rim'  Spielerei  ist.  " 

Under  the  dry  plan  of  treatment  a  hunch  of  gauze  or  a  marine  sponge  is 
grasped  in  a  long  holder  and  carried  down  to  the  bottom  of  the  pelvis,  which 
is  then  repeatedly  sponged  out  until  clean.  A  fresh  sponge  is  carried  over  into 
the  right  and  left  renal  regions;  the  mesenteric  folds  are  inspected,  and  the  upper 
ami  the  under  surfaces  of  the  liver.  A  general  agglutination  of  the  intestines 
in  situ  is  not  a  had  sign  and  ought  not  to  be  disturbed.  In  introducing  the  sponge 
first  iido  one  quarter  and  then  into  another,  it  should  he  carried  up  close  to 
the  abdominal  wall.  After  drying  out  the  disease  without  spending  much 
time  in  picking  off  plates  of  lymph,  the  abdomen  is  closed,  drains  being  inserted 
i  tending  either  from  the  median  incision  down  into  the  fossa  and  into  the 
pelvis,  or  through  fresh  openings  into  the  sides,  and,  in  women,  into  the  vagina. 
This  line  of  treatment  accords  with  the  recommendation  made  by  Tietze  in 
1889  (Die  chir.  Behandl.  der  akut.  Periton.). 

1 )  r  a  i  n  a  g  e  . — After  opening  the  abdomen,  cleansing  it  of  poisonous  secre- 
tions, and,  if  possible,  removing  the  focus  of  trouble,  the  appendix,  the  next 
step  is  to  provide  against  further  accumulation  and  absorption  of  septic  mate- 


DIFFUSE  PURULENT  PERITONITIS.  653 

rial  by  an  efficient  plan  of  drainage.  If  the  pat  ii 'nt  seems  to  be  almost  in extremi  . 
and  there  is  a  large  accumulation  in  the  abdomen  to  be  opened,  the  surgeon 
may  not  be  able  to  do  more  than  make  an  incision  under  cocaine,  lei  oul  as 
much  pus  as  will  escape  spontaneously,  and  insert  a  large  rubber  drainage-tube. 

In  less  serious  cases  a  gauze  drain,  whether  washed-out  iodoform  gauze  or  plain 
sterilized  gauze,  acts  well  for  a  few  hours  or  a  day,  but  after  that  time  it  ceases 
In  affect  any  area  greater  than  that  directly  in  contact  with  the  gauze  itself. 
The  meshes  of  the  gauze  then  become  plugged,  and  if  left  in  situ,  it  is  apt  to 
choke  the  opening  in  the  abdomen,  and  bottle  up  the  secretions,  rather  than 
promote  their  escape.  To  avoid  this  ill  effect  it  is  well,  in  some  cases,  after 
the  first  day,  to  begin  to  pull  the  gauze  out,  and  so  keep  it  moving  day  by  day 
until  the  whole  is  removed.  The  "cigarette  drain"  used  by  .Morris,  of  New 
York,  and  Warren,  of  Boston,  answers  this  purpose  excellently;  it  is  made  up 
of  sterilized  gauze,  rolled  in  rubber  tissue,  and  can  be  made  of  any  calibre,  is 
soft  and  flexible,  and  does  not,  like  the  unprotected  gauze,  stick  to  the  tissues 
within,  giving  great  pain  with  its  removal. 

Rubber  tubing  from  G  to  8  inches  long  and  J  to  \  inch  in  diameter,  introduced 
and  surrounded  by  gauze,  also  affords  an  efficient  drain  which  is  not  liable  to 
become  plugged.  If  the  removal  of  a  drain  is  painful,  a  little  nitrous  oxide 
gas  will  overcome  the  difficulty. 

F.  Bode  (Centralbl.  f.  Chir.,  1900,  Bd.  27,  p.  33)  describes  "A  new  method  of 
treatment  of  the  peritoneum  and  drainage  in  diffuse  peritonitis"  as  follows:  An 
extensive  incision  is  made  with  the  pelvis  elevated,  and  the  peritoneal  cavity 
eviscerated,  as  far  as  possible,  under  a  continuous  irrigation  of  a  warm  saline 
solution.  The  separate  coils  of  intestine  outside  of  the  abdomen  are  then  wrapped 
up  iii  compresses  wet  with  salt  solution  and  irrigated  afresh,  from  time  to  time, 
to  prevent  any  chilling.  Bode  says  that  under  this  treatment,  patients  with 
a  small  rapid  pulse,  so  far  from  collapsing,  began  to  improve  on  account  of  the 
relief  of  tension  and  the  removal  of  toxic  materials.  The  point  of  perforation 
now  being  found  and  treated,  and  the  abdominal  cavity  disembarrassed  of  its 
contents,  the  abdomen  is  washed  out  with  30  to  40  litres  of  salt  solution,  especial 
attention  being  given  to  the  upper  surfaces  of  the  liver  and  the  neighborhood  of 
the  spleen,  as  well  as  to  the  pelvis.  The  peritoneum  is  then  carefully  and  gently 
cleaned  with  compresses,  the  coils  of  intestines  are  also  cleansed,  and  returned 
under  saline  irrigation  into  the  abdomen.  At  this  juncture  a  bunch  of  the 
small  intestines  from  about  the  middle  of  the  abdomen  is  grasped  and  lifted 
up,  bringing  the  mesentery  into  view.  The  mesentery  is  then  perforated  near  its 
root,  at  a  point  free  from  vessels,  and  a  thick  and  correspondingly  long  drainage- 
tube  with  openings  in  its  walls,  is  passed  through  the  mesentery  and  out  of  the 
right  and  left  walls  of  the  abdomen  over  the  colon.  Besides  this  principal 
drainage-tube,  another  is  introduced  from  each  of  the  lateral  wounds,  with  a 
fourth  from  the  median  incision  extending  to  the  deepest  part  of  the  pelvis. 
Further  drainage-tubes  are   introduced,  if  necessary,  to  the  neighborhood   of 


654  PERITONITIS. 

the  liver,  stomach,  and  spleen,  after  which  the  incision  is  closed  with  through- 
and-through  sutures.  By  pouring  in  fresh  salt  solution  as  the  wound  is  being 
closed,  a  do!  inconsiderable  quantity  of  fluid  is  left  behind  in  the  abdomen.    The 

patient  is  put  to  lied  with  the  head  elevated  to  favor  the  downward  flow  of  any 
pus,  which  is  then  washed  out  through  the  drainage-tubes  by  running  in  salt  solu- 
tion, 1000  to  1500  cc.  twice  or  three  times  daily.  Under  such  treatment  con- 
siderable pus  escape-,  peristalsis  begins,  gas  passes,  and  the  bowels  move. 

Treatment  of  the  Distended  Intestines. — If  the  in- 
testines are  so  distended  that  they  can  only  he  returned  to  the  abdominal  cavity 
with  difficulty,  and  if  there  exists  a  large  accumulation  of  fluid  within  the  ileum, 
McCosh's  plan  of  bringing  the  loops  of  the  intestine  outside,  incising,  emptying, 
and  then  closing  and  returning  the  bowel  may  sometimes  he  tried  with  advan- 
tage. Where  the  intestines  are  paralyzed  an  enterosto  m  y  has  saved  life 
in  numerous  instances.  This  is  best  executed  by  keeping  the  wound  open  and 
leaving  one  of  the  distended  loops,  as  near  as  possible  to  the  cecum,  exposed  in  the 
wound,  simply  covering  it  with  a  pad  of  iodoform  gauze.  In  order  to  mark  the 
exact  spot  for  the  opening,  two  line  black  silk  sutures  may  be  inserted  about 
2  cm.  apart  into  the  outer  coats  of  the  bowel,  and  left  hanging  out  of  the  wound. 
Then  after  six  or  seven  hours,  or  more,  the  dressings  are  removed,  the  sutures 
picked  up  and  held  apart,  and  a  small  opening  about  1  cm.  in  length  is  made 
into  the  lumen  of  the  bowel,  affording  exit  for  gases  and  fecal  material.  The 
attention  of  the  profession  has  been  called  to  this  mode  of  treatment  by  W.  W. 
Van  Arsdale  in  a  paper  entitled  ''The  treatment  of  the  intestinal  "paralysis 
of  peritonitis  by  enterostomy"  (Ann.  Surg.,  1889,  vol.  29,  p.  1). 


CHAPTER   XXVIII. 

CARE  OF  PATIENT  AFTER  OPERATION  AND  POST-OPERATIVE 

SEQUELAE. 

CARE  OF  PATIENT  AFTER  OPERATION. 

All  is  not  finished  with  the  completion  of  the  operation.  Success  or  failure 
still  largely  depends  upon  the  intelligent,  watchful  after-care  of  the  surgeon  ami 
the  nurse;  proper  attention  to  many  seemingly  trivial,  yet  important  details 
during  the  first  two  or  three  weeks  following  operation  will  often  do  much  to 
shorten  the  period  of  true  convalescence. 

The  surgeon  must  always  hear  in  mind  that  there  are  two  factors  in  every 
convalescence,  namely,  the  recovery  from  the  wound  and  the  disease,  and  the 
recovery  of  the  nervous  system  from  the  exhaustion  caused  by  the  illness  and 
the  shock  of  the  operation.  From  the  patient's  standpoint,  his  convalescence 
is  divided  into  two  periods:  a  first,  in  which  he  is  confined  to  bed;  and  a  second, 
in  which  he  is  up  and  looking  forward  to  complete  recovery  of  his  strength 
and  the  entire  removal  of  the  discomforts  left  by  the  operation.  During  the 
whole  period  of  convalescence  the  physiologic  economy  of  the  man  is  actively 
engaged  in  striking  a  fresh  balance  with  his  resources,  in  order  that  he  may  once 
more  enter  upon  the  duties  of  life  with  renewed  vigor. 

It  is  a  fond  superstition  of  the  laity,  often.  I  am  sorry  to  say  encouraged 
by  physicians,  that  the  convalescent  period  is  shortened  by  hustling  the  patient 
out  of  bed  a  few  days  after  the  operation ;  while,  on  the  contrary,  it  is  often 
lengthened  by  such  treatment.  I  have  seen  patients,  untimely  thrust  from 
the  hospital,  and  reported  as  "up  in  eight  days,"  who.  weeks  afterward, 
were  still  feeling  miserable,  and  unable  to  work.  It  is  possible,  of  course,  to 
get  a  patient  out  of  bed  in  eight  days,  and  they  may  do  well  in  spite  of  this  treat- 
ment, but  it  is  not  to  their  best  interests,  and  it  does  not  really  shorten  the  con- 
valescent period,  which  truly  ends  only  when  they  are  able  to  resume  their 
normal  activities  with  zest. 

I  also  mention,  only  to  condemn,  the  practice  pursued  by  some  surgeons 
of  performing  the  operation,  and  then  leaving  the  patient  entirely  in  the  hands 
of  a  medical  man  without  experience  in  surgical  work.  When  the  case  is  remotely 
situated  in  the  country,  this  may  be  unavoidable,  or  a  choice  of  evils,  but  even 
under  these  circumstances,  a  trained  assistant  should  either  remain  behind  or 
make  some  subsequent^  visits.  It  is  never  justifiable  to  operate  and  then  aban- 
don the  patient,  as  a  compliment  to  the  family  physician,  who  is  anxious  to 

655 


656    CARE   OF    PATIENT   AFTER   OPERATION    AND   POST-OPERATIVE   SEQUELAE. 

enhance  his  services  in  the  eyes  of  t lit*  relatives.  The  man  who  does  this  is 
treating  his  surgery  in  the  light  of  a  trade. 

The  post-operative  period  requiring  the  greatest  watchfulness  and  care, 
extends,  in  the  average  case,  over  the  first  five  or  six  days,  during  the  firsl  two 
or  three  of  which  the  patient  is  getting  over  the  shock  of  the  operation  and 
the  nausea  caused  by  the  anesthetic;  a  day  or  two  longer  is  required  to  re- 
establish the  much  desired  regular  activity  of  the  bowels. 

The  signs  of  a  normal  convalescence  following  a  surgical  operation  which  is 
the  termination  of  a  protracted  illness,  are  to  the  anxious  bystanders  what  the 
rest  of  a  quiet  harbor  is  to  the  storm-driven  mariner.  With  extreme  satisfaction 
does  the  surgeon  announce  to  the  anxious  family  the  hourly  improvement,  mani- 
fested by  the  falling  temperature,  the  full,  steady,  quiet  pulse,  tin'  decreasing 
abdominal  tenderness  and  softening  of  the  abdominal  walls,  the  diminution 
of  pain,  and  the  passage  of  flatus.  As  improvement  progresses,  the  patient 
recovers  a  sound  healthy  color,  his  interest  in  his  surroundings  quickens, 
annoying  thirst  is  replaced  by  a  sound,  healthy  hunger,  and  the  halm  of 
sweet  refreshing  sleep  during  the  night  extends  its  blessing  over  the  waking 
period. 

If  convalescence  proceeds  uninterruptedly  after  this  manner,  the  patient 
may  rise  from  bed  in  two  weeks,  but  he  is  wiser  if  he  consents  to  stay  there  for 
three;  then  for  a  few  days,  if  the  weather  permits,  he  should  be  wheeled  in  a 
rolling  chair  into  the  fresh  air;  a  little  later  still  he  takes  a  few  steps,  and 
so,  in  five  or  six  weeks  he  dispenses  with  nurses  and  doctors  and  is  able  once 
more   to  care  for  himself. 

If  the  wound  is  a  small  one,  and  especially  if  the  muscular  fibres  have  not 
been  much  out,  it  is  not  necessary  that  the  patient  should  wear  an  abdominal 
bandage,  which  is  at  best  but  an  awkward  contrivance  for  giving  support  over 
the  iliac  fossa.  Where  the  wound  is  extensive,  however,  and  above  all  where 
there  has  been  drainage,  a  snug,  supporting  bandage  should  be  worn  for  six 
months  or  longer. 

Nursing.  —  It  is  of  the  utmost  importance  that  the  nurse  should  be  personally 
acceptable  to  the  patient  as  well  as  one  well  trained  in  abdominal  surgery.  In 
a  simple,  uncomplicated  case  of  appendicitis  one  nurse  may  suffice,  but  if  the 
patient  is  critically  ill.  two,  or  even  three  will  be  required. 

Immediately  after  the  operation  the  patient  should  be  placed  in  a  warm  bed, 
carefully  prepared.  The  room  must  be  darkened,  the  air  kept  fresh  and  sweet 
at  a  temperature  of  about  63°  F.  Absolute  quiet  must  be 
maintained,  and  members  of  the  family  should,  as  a  rule,  be  excluded 
for  .several  days.  The  first  person  admitted  should  be  that  near  relative  whose 
presence  is  pleasant  and  comforting  to  the  patient,  the  rule  being  imposed 
that  "silence  is  golden."  The"  surgeon  must  constantly  bear  in  mind  that 
he  has  under  his  care  a  wound  which  is  healing  and  a  nervous  system  which 
is  recovering  its  balance  after  a  severe  shock;  the  latter  is  longer  in  reeup- 


AFTER-CARE    OF    PATIEXT.  G.")7 

crating  than  the  former,  and  nothing  so  much  delays  this  part  of  the  con- 
valescence as  excessive  visiting.  Xo  outside  visitors  should  be  admitted  for 
several  weeks. 

Posture  . — The  best  posture  for  the  patient  is  on  the  back  with  the 
knees  slightly  flexed,  but  he  should  be  turned  occasionally  on  the  right  side 
to  rest  the  tired  muscles.     The  moving  must  always  be  done  by  the  nurse. 

Sedatives  . — Severe  pain  must  be  relieved  by  hypodermics  of  morphine, 
say  one-eighth  of  a  grain  repeated  in  twenty  minutes  if  neccessary,  during 
the  first  twenty-four  to  forty-eight  hours  whenever  the  pain  becomes  unbearable. 
In  the  case  of  a  child  it  is  best  to  give  one  thirty-second  to  one-eighteenth  of 
a  grain  every  twenty  minutes  until  the  pain  is  relieved.  In  ordinary  cases 
no  morphine  should  be  given  after  the  first  forty-eight  hours,  as  its  continued 
use  retards  recovery;  and  it  may  be  laid  down  as  a  good  general  rule  that  the 
less  morphine  given,  the  more  satisfactory  is  the  convalescence.  In  some  cases 
a  grain  of  the  aqueous  extract  of  opium  in  a  suppository  works  better  than  the 
morphine,  exerting  a  more  direct  local  influence. 

Diet. — All  nourishment  should  be  suspended  after  the  operation  until 
the  stomach  is  settled.  The  first  food  given  should  be  egg  albumen,  prepared 
by  beating  the  whites  of  four  eggs  to  a  froth,  and  allowing  it  to  stand  in  a  cool 
place  for  an  hour  or  more,  when  the  liquid  (about  50  cc.)  can  be  drained  off, 
leaving  the  frothy  part  behind.  It  is  best  to  give  a  teaspoonful  at  a  time  mixed 
in  two  or  three  tablespoonfuls  of  cold  water  with  a  little  sugar  and  five  or  ten 
drops  of  lemon  juice.  It  may  also  be  given  in  ginger  ale,  in  orange  juice,  or  in 
sherry  wine.  About  the  third  or  fourth  day  soft  food  may  be  given,  and  after 
the  first  week  a  stronger  diet  may  be  gradually  resumed.  As  a  rule,  attendants 
are  over-anxious  to  feed  patients,  who  can  often  stand  absolute  starvation  for 
four  or  five  days  very  well.  Where  the  stomach  has  been  much  disturbed 
previous  to  operation,  J.  F.  Mitchell  has  found  it  of  great  service  to 
wash  it  out  on  the  operating  table,  using  abundance  of  warm  water,  and 
continuing  until  the  washings  return  clear.  In  cases  which  suffer  from  per- 
sistent nausea  after  the  operation,  with  no  other  ill  symptoms,  one  or  two 
good  washings  often  bring  great  relief. 

Care  of  the  Wound. — Protection  from  exposure,  and  rest  are  the  two 
important  factors  in  the  care  of  the  wound.  Protection  is  best  secured  by  the 
dressings,  held  in  place  by  a  suitable  bandage  applied  at  the  conclusion  of  the 
operation,  in  such  a  way  as  to  cover  the  right  iliac  fossa,  the  groin,  the  upper 
right  thigh,  and  the  lumbar  region.  If  the  bandage  is  snugly  applied,  the 
parts  are  immobilized,  and  the  formation  of  a  loose  sliding  plane  between  the 
dressings  and  the  body  is  avoided.  An  infected  wound  may  easily  arise  from 
dressings  loosely  applied  or  which  have  worked  loose  in  the  convalescence; 
in  such  a  case  every  movement  of  the  body,  every  deep  respiration,  tends  to 
suck  in  the  air  beneath  the  bed-clothes  and  to  bring  gross  particles  into  contact 
with  the  incision.  To  avoid  this,  the  dressings  and  the  bandages  must  be 
42 


658    <   \KI.   OF    PATIENT   AFTEB   OPERATION    AND   POST-OPERATIVE   SEQUELAE. 

properlj  placed,  secured  it'  accessary  by  adhesive  straps,  and  watched  as  well, 
tn  make  sure  that  they  arc  not  loose  or  slipping  upward.  To  insure  rest,  the 
patient  must  lie  in  perfect  repose  during  the  first  days  of  convalescence,  above 
all  avoiding  any  use  of  the  right  leg.  All  movements  must  be  of  a  passive  nature, 
effected  by  the  skilled  hands  of  the  nurse  or  of  the  medical  attendant.  If  all 
well,  as  shown  by  pulse,  temperature  chart,  and  general  condition,  the 
wound  should  not  be  disturbed  for  from  seven  to  nine  days,  when  all  the  dressings 
may  be  removed  with  care,  and  the  pails  contiguous  to  the  wound  cleansed 
with  alcohol  and  water,  or  soap  liniment,  and  some  fresh  lighter  dressings 
applied.  If  there  is  a  subcuticular  wire  or  catgut  suture,  it  may  be  drawn 
out  at  this  time.  A  few  days  later  all  dressings  may  be  removed,  and  the 
wound  simply  covered  with  a  pad  of  gauze  to  protect  the  tender  tissues  from 
violence. 

If  for  any  reason  the  patient  does  badly,  the  pulse  and  temperature  pi  up, 
the  general  condition  cause  any  anxiety,  or  if  there  is  much  persistent  pain,  the 

wound  should  always  1 xamined.     If  it  is  found  sensitive,  red,  and  puffy 

or  swollen  at  any  part,  it  should  he  opened  at  once  under  a  little  cocaine,  and 
then,  if  pus  is  found,  poulticed.  It  is  a  mistake  to  try  to  let  out  the  pus  through 
a  small  orifice  under  these  circumstances;  the  focus  of  infection,  whether  ju-t 
under  the  -kin  or  lower  down,  must  he  regarded  as  the  apex  of  a  pyramid  whose 
hase  is  at  the  skin  surface.  It  is  always  unfortunate  when  the  infection  ex- 
tends down  into  the  iliac  fossa  to  the  seat  of  the  operation  on  the  bowel,  hut 
if  the  condition  is  recognized  promptly,  and  effectively  treated  by  thorough 
exposure  and  drainage,  the  misfortune  is  limited,  after  all.  to  a  delayed  conva- 
lescence, and  the  risk  of  a  hernia  at  a  later  date.  Even  when  the  bowel 
breaks  down,  ami  a  fecal  fistula  is  established,  it  is.  as  a  rule,  hut  temporary, 
and   exhibits  a   remarkable    tendency   to    rapid   spontaneous  closure  within  a 

few  weeks. 

Care  of  the  Bowels. — The  movement  of  the  bowels  gives  as  much  cause  for 
anxiety  as  any  single  feature  in  the  average  convalescence.  When  the  surgeon 
has  mastered  the  complications,  the  appendix  has  been  removed,  and  the  wound 
well  closed,  no  anxiety  need  he  felt  as  to  the  administration  of  the  necessary 
purgative  for  moving  the  bowels.  If  it  is  a  matter  of  importance,  as  it  is  in 
some  cases  of  appendicitis,  that  they  should  move  soon,  the  plan  pursued  by 
J.  M.  T.  Finney  may  he  adopted,  and  about  six  ounces  of  a  saturated  solution 
of  Epsom  salts  run  into  the  stomach  at  the  conclusion  of  the  operation.  The 
-aline  given  in  this  way  is  rarely  vomited,  and  a  satisfactory  evacuation  may 
be  secured  as  early  as  eight  hours  later.  In  severe  cases  one  or  two  drops  of 
croton  oil  may  he  administered  in  this  way.  If  purgation  is  not  urgent,  a 
substantial  dose  of  calomel  may  be  given  on  the  second  day,  followed  by  an 
enema  in  from  eight  to  twelve  hours,  or  broken  doses  of  calomel  may  tie  given, 
say  a  sixth  of  a  grain  every  hour,  followed  by  an  enema  in  about  eight  hours. 
A  teaspoonful  of  liquorice  powder  of  the  German  Pharmacopoeia  answers  very 


AFTER-CARE    OF    PATIENT.  659 

well  with  some  patients.  Birrell  uses  a  saline  cathartic  whenever  then'  is 
a  rise  in  temperature,  a  quickened  pulse,  and  a  glazed  tongue  He  gives  a 
saturated  solution  of  salts  in  tablespoonful-doses,  taken  in  soda  water  from 
a  siphon,  and  very  cold.  This  may  be  repeated  from  hour  to  hour.  After 
giving  sufficient  purgatives  and  using  an  enema,  it  is  well  to  wait  for  six  to 
eight  hours  and  give  nature  a  chance  to  act,  if  the  case  is  doing  well  in  other 
respects.  The  bowels  will  then  often  move  spontaneously  and  satisfactorily 
without  further  stimulus.  The  doctor  and  nurse  must  be  careful  not  to  let 
their  good  judgment  fail  them  through  an  over-anxiety  to  hasten  the  move- 
ment; too  many  or  too  severe  purgatives  may  leave  behind  a  troublesome 
diarrhea. 

Urine. — A  free  flow  of  normal  urine  is  one  of  the  reassuring  signs  during 
convalescence.  The  urine  should  be  kept,  measured,  and  examined  in  all 
cases;  if  albumen  or  casts  have  been  found  in  the  urine  before  operation,  it 
will  naturally  be  watched  with  greater  care  during  convalescence  and  the  gradual 
disappearance  of  these  pathologic  elements  hailed  with  satisfaction.  Kidneys 
which  have  been  injured  by  a  septic  storm  are  best  cared  for  by  promoting  a 
free  flow  of  bland  urine,  and  this  is  accomplished  in  most  cases  by  giving  a 
hypodermocleisis  of  GOO  to  1000  cc.  of  normal  salt  solution,  administered  on 
the  operating  table,  and  repeated  once  or  twice  in  each  twenty-four  hours  for 
several  days. 

Severe  and  Fatal  Cases. — The  surgeon  must  always  feel  that  a  patient 
who  has  strength  enough  to  pull  through  an  operation  and  live  for  two  or  three 
days  afterward,  ought  to  recover,  unless  some  unforeseen  and  unavoidable 
sequela?,  such  as  a  metastatic  abscess,  pneumonia,  or  em- 
bolism, should  occur.  It  sometimes  happens,  however,  that  a  case  which 
would  otherwise  recover,  fails  to  do  so  from  some  defect  in  technic,  not  neces- 
sarily due  to  a  fault  on  the  part  of  the  surgeon,  but  arising  rather  from  our  still 
imperfect  knowledge  as  to  the  best  method  of  drainage,  the  propriety  of  drain- 
ing at  all,  or  some  other  vital  point.  The  conditions  which  should  occasion 
anxiety  are  as  follows  ; 

Persistent  pain,  usually  associated  with  elevation  of  tem- 
perature, is  a  sign  of  suppuration  in  the  wound  or  beneath  it.  and 
the  local  condition  should  he  investigated  at  once.  A  quick  pulse 
and  persistent  nausea,  growing  worse  rather  than  better,  point 
toward  septic  peritonitis.  A  distended  a  b  d  omen  a  c  c  o  m  p  an  ied 
b  y  v  o  in  i  t  i  n  g  is  an  indication  for  the  evacuation  of  the  intestinal  tract. 
If  auscultation  reveals  gurgling  it  is  reassuring  evidence  in  case<  of  paresis  of 
intestinal  activity,  showing  that  the  intestines  are  capable  of  performing  their 
normal  functions. 

Psychic  disturbances,  such  as  great  restlessness, 
persistent  painful  wakefulness,  or  too  eager  assur- 
ance   of    recovery,    are  often  associated  with  profound  septic  troubles. 


660    CAHB   OF  PATIENT   AFTER  OPERATION    AND  POST-OPERATIVE   SEQ1  ELM. 

Where  not  the  signs  of  a  graver  trouble,  they  should  be  combated  with  mild 
sedatives,  such  as  bromides,  trional,  heroin,  etc. 


POST-OPERATIVE  SEQUELAE. 

Introductory. — It  is  an  unfortunate  fact  that  the  conclusion  of  an  opera- 
tion ilocs  not  invariably  terminate  all  anxiety  as  to  the  patient's  recovery. 
Oftentimes  the  operation,  especially  if  it  lias  been  difficult,  is  followed  by  a 
more  or  less  stormy  convalescence,  interrupted,  it  may  be,  by  sequelae  which 
seriously  threaten  life  itself. 

Many  of  these  disturbances  are  common  to  all  major  surgical  procedures  in 
which  an  anesthetic  has  been  used,  such,  for  example,  as  n  a  u  s  e  a  and  v  o  in  - 
i t i n g ,     h i c c o u  g h ,     e x  t r e m e     nervousness,     excessiv e 

p  a  in  ,  sleeplessness,  ami  m  a  rj  i  a  .  Other  sequelae  are  those  mine 
peculiarly  associated  with  lower  abdominal  operations,  especially  such  as  involve 
infected  areas,  e.  </..  peritonitis,  abscesses  forming  in  or  under- 
neath the  wound,  ileus,  phlebitis,  p  n  e  u  m  o  n  i  a  o  f  e  m  b  oli  c 
origin,   or   s  e  p  t  i  c    p  le  ur  is  y  . 

The  character  of  the  post-operal ive  sequelae  is  apt  to  vary  according  as 
the  case  has  been  simple  or  difficult,  and  for  this  reason  it  is  possible  to  antici- 
pate certain  evils  according  to  the  nature  of  the  preceding  illness;  for  example, 
after  a  simple  removal  of  the  appendix,  only  such  disturbances  are  apt  to  arise 
a-  affect  the  earliest  period  of  convalescence,  e.  '/.,  t  y  m  p  a  n  y  f  r  o  m  a  t  o  n  y 
o  f  t  h  e  I)  o  w  e  1  .  or  p  a  i  n  arising  from  a  s  i  m  p  1  e  t  r  a  u  in  a  t  i  c  p  er  i  - 
ton  i  t  is  .  After  a  more  serious  operation,  in  which,  for  instance,  an  abscess 
has  been  opened  or  the  peritoneum  has  been  soiled,  the  anxiety  of  the  medical 
attendant  during  the  first  few  days  of  convalescence  is  concentrated  upon  those 
symptoms  which  point  toward  a  fresh  accumulation  of  pus,  to  a 
s  p  r  e  a  d  i  n  g  peritonitis,  or  an  intestinal  o  h  s  t  r  u  c  t  inn. 
The  best  guarantee  against  the  onset  of  serious  symptoms  during  the  convalescent 
period  is  the  correct  performance  of  every  step  of  the  operation,  and  the  recol- 
lection of  having  done  this  is  a  source  of  great  comfort  to  the  operator.  Careful 
work  and  painstaking  attention  to  detail  are  the  best  prophylactics  against 
accidents  during  convalescence,  and  many  of  the  most  serious  post-operative 
sequela'  may  lie  obviated  l>y  these  means.  Moreover,  the  peculiar  difficulties 
of  an  operation  often  throw  light  upon  the  possible  sequela?  and  suggest 
means  of  obviating  them.  If.  after  closing  the  stump,  it  is  well  embedded  in 
the  cecum,  it  will  not  then  contract  adhesions  with  the  bowel  or  omentum. 
By  avoiding  undue  handling  of  the  intestines  and  the  adjacent  peritoneum  the 
delicate  epithelium  i-  spared  abrasions,  and  traumatic  peritonitis 
with  adhesions  will,  to  a  large  extent,  be  avoided.  In  using  a  retractor,  gnat 
care  must  be  taken  not  to  bruise  the  iliac  vein;  as  this  precaution  insures  against 
one   prolific  cause  of  p  h  1  e  b  i  t  i  s  .     By  thorough  cleansing  of  abscess 


VARIETIES    OF   SEQUEL.K.  GG1 

cavities  and  the  freest  possible  drainage,  the  necessity  of  opening  them 
again  at  a  later  date  will  often  be  obviated.  Second  a  r  y  o  p  e  r  a  t  i  o  ns 
will  also  be  avoided,  if  the  surgeon  is  careful  at  the  time  of  the  first  operation  to 
locate  other  abscesses  in  the  pelvis,  among  the  intestines,  or  in  the  flanks,  and 
to  drain  them  in  their  most  dependent  portions.  An  extension  of  per- 
itonitis by  the  extravasation  of  feces  a  few  days  after  the  operation  will  be 
avoided  if  torn  and  sutured  intestinal  areas  are  brought  out,  with  less  hesitation 
than  is  usual,  and  left  exposed  to  view  in  the  open  abdominal  wound.  When 
an  operation  is  undertaken  for  an  ileus,  the  surgeon  will  often  be  spared 
the  mortification  of  repeating  it,  if  he  examines  carefully  all  the  adjacent  coils 
of  intestine  to  make  sure  that  he  has  not  overlooked  any  important  adhesions. 
Hernia  is  best  avoided  by  operating  early,  before  the  advent  of  such  symp- 
toms and  complications  as  necessitate  drainage  of  the  wound,  that  is  to  say, 
by  a  very  early  operation,  or  by  one  in  the  interval. 

If  we  look  at  these  sequela1  according  to  their  relation  in  time  to  the  original 
operation,  we  may  conveniently  divii  le  them  into  early,  intermediate, 
and  late. 

Early  sequela?  are  those  associated  with  the  anesthetic,  the  nervous 
condition  incident  to  the  operation,  and  the  continuation  of  those  disturbances 
which  are  projected  forward  into  the  time  of  convalescence  from  the  pre-oper- 
ative  stage,  such  as  the  extension  of  a  peritonitis. 

Intermediate  sequela1  are  those  which  begin  a  few  days  to  a  few- 
weeks  after  the  operation,  and  are  caused  by  the  evolution  of  an  abscess, 
by  an  ileus,  the  formation  of  a  phlebitis,  or  the  lodgment  of  an 
e  m  bolus. 

Late  sequels,  which  may  arise  months  or  years  after  the  original 
operation,  are  hernia  in  the  scar,  and  i  n  t  e  s  t  i  n  a  1  o  b  s  t  r  u  c  - 
t  i  o  n  . 

Homer  Gage  reports  that  out  of  22S  cases  operated  upon  for  appendicitis 
whose  subsequent  history  he  was  able  to  trace  (in  many  of  which  the  abscess 
was  simply  drained),  42  made  complaints  of  one  sort  or  another  on  inquiry. 
Out  of  54  cases  there  was  a  recurrence  in  10  per  cent.  In  a  number  of  instances, 
however,  the  replies  indicated  that  the  complaints  were  of  long  standing,  and 
not  post-operative.  Thirteen  complained  of  more  of  less  discomfort  in  the  region 
of  the  scar;  of  soreness  caused  by  exercise;  of  pain  on  the  approach  of  a  storm; 
of  a  weakness  noticeable  most  of  the  time.  Every  operator  is  familiar  with 
the  complaint  of  persistent  pain  in  the  neighborhood  of  the  wound,  and  the  asser- 
tion that  the  discomfort  is  the  same  as  it  was  before  the  appendix  was  removed. 
Some  of  these  discomforts  are  caused  by  the  large,  tender  scar;  some,  undoubt- 
edly, are  due  to  the  injury  of  nerve  fibres  during  the  operation;  others  to  a  local- 
ized peritonitis  and  adhesions  about  the  head  of  the  cecum.  One  of  Gage's 
cases  was  a  young  school-teacher,  whose  appendix  had  been  removed  in  the 
interval,  and  who  experienced  such  severe  pain  in  the  region  of  the  scar,  with 


662    <   MM.    OF   PATIENT   AFTEB   OPERATION    AND   POST-OPERATIVE   SEQUELS. 

tenderness  over  the  upper  end,  that  she  had  to  give  up  her  work  and  go  to 
bed.  On  re-opening  the  abdomen  an  adhesion  of  the  omentum  was  found, 
about  half  an  inch  square.    This  was  liberated,  and  the  relief  was  immediate 

and     complete,    all     pain     and     tenderness    disappeared,    and    she    was    aide    to 

resume  her  occupation.  In  another  case  a  woman,  thirty-five  years  old, 
complained  of  great  soreness  and  tenderness  in  the  region  of  the  scar,  which 
was  excised  and  freed  with  equal  success;  some  omental  adhesions  also  were 

freed. 

-  netimes  the  pain  in  the  iliac  fossa  simulates  the  old  attacks  of  appendicitis, 
hut  this,  for  the  most  part,  wanes  steadily,  and  disappears  alter  some  months 
or  a  year.  In  one  case,  however,  occurring  at  the  Johns  Hopkins  Hospital, 
a  man  had  such  definite  attacks  following  operation  that  it  was  at  last  thought 
the  appendix  could  not  have  been  removed.  ( >n  a  second  operation,  however, 
there  proved  to  be  nothing  at  the  site  of  the  organ  but  adhesions. 

One  of  the  most  troublesome  sequela  is  an  area  of  anesthesia 
over  the  lower  abdomen  at  some  point  between  the  scar,  the  median  line,  and 
the  symphysis.  This  is  due  to  the  injury  done  by  division  of  the  sensory  nerve 
fibres,  and  is  best  avoided  by  a  careful  dissection  with  blunt  separation  of  the 
tissues,  the  nerve  trunks  thus  being  spared.  The  division  of  the  nerves  entering 
the  rectus  muscle  across  the  semilunar  line  is  often  responsible  for  a  marked 
atrophy  of  the  muscle  and  a  thinning  of  the  abdominal  wall.  This  serious 
accident  is  also  easily  avoided  by  duly  respecting  the  nerves,  when  the  tissues 
are  divided  in  opening  the  abdomen  (Lennander). 

Hemorrhage. — A  post-operative  hemorrhage  may  take  place  from  some 
vessel  large  enough  to  cause  a  serious  loss  of  blood,  which  may  have  been  perfectly 
controlled  during  the  operation  by  the  crushing  power  of  the  clamp.  A  warning 
example  of  this  contingency  is  frankly  furnished  by  R.  L.  Payne,  of  Norfolk, 
Virginia,  who.  when  operating  upon  a  child,  divided  and  clamped  the  epigastric 
artery  while  making  the  abdominal  incision,  and  in  the  anxiety  ami  hurry 
attendant  upon  a  difficult  operation,  no  ligature  was  applied,  as  there  was  no 
bleeding  when  the  clamp  was  removed.  The  wound  hail  to  he  drained,  and 
when  the  hemorrhage  occurred,  although  there  was  every  opportunity  for 
the  nurse  to  call  the  surgeon,  she  did  not  do  so,  until  the  patient  had  Med 
to  death,  when  all  the  dressings  and  the  bed  were  found  saturated  with 
blood. 

Sir  Dyce  Duckworth  Med.  and  Surg.  Trans.,  1889,  vol.  72,  p.  433)  operated 
upon  a  boy  of  sixteen,  for  the  removal  of  an  appendix  which  was  gangrenous 
for  two-thirds  of  its  length.  The  patient  did  well  for  eight  days,  when  he  began 
to  have  pain  in  the  region  of  the  wound,  for  which  half  a  grain  of  the  extract 
of  opium  was  administered.  As  the  pain  continued  to  increase,  the  dressings 
were  removed  and  a  large  blood-clot  was  found;  this  was  removed,  but  the 
source  of  the  hemorrhage  could  not  he  discovered.  The  drainage-tube  in  use 
was  then  replaced  by  a  plug  of  iodoform  and  lint,  and  the  wound  tightly  ban- 


SUPPURATION    OF   ABDOMINAL    WOUND.  GG3 

daged.     In    the  afternoon  the  wound  was  dressed,   and  a  quantity  of  dark, 
clotted,  and  grumous  blood  removed;   recovery  followed. 

Walch  (Havre),  under  the  title  "Hemorrhagic  intestinale  grave  a  In  suite 
d'une  operation  d'appendicite  a  froid  "  (Bull  et  mem.  de  la  Soc.  dt  chir.  de  Pat 
toni.  27,  p.  374),  cites  a  case  in  which  he  resected  the  appendix  in  a  man  forty 
years  old.  three  months  after  an  attack  of  appendicitis.  He  placed  a  ligature 
around  the  base  of  the  appendix,  but  did  uot  cover  the  stump  with  the  serosa. 
Three  days  later  the  temperature  rose,  and  the  man  developed  an  undoubted 
right-sided  pleurisy.  Six  days  after  the  operation  he  became  suddenly  worse, 
and  suffered  from  tenesmus,  followed  by  the  sudden  discharge  of  an  enormous 
quantity  of  blood  from  the  rectum;  in  addition  to  three  litres  discharged  in  this 
way,  he  vomited  about  300  to  400  cc.  of  blood  mixed  with  the  contents  of  the 
stomach.  Walch  believed  that  the  bleeding  proceeded  from  the  site  of  the 
operation,  on  account  of  the  manifestly  arterial  tint  of  the  blood,  and  he  con- 
sidered that  the  hemorrhage  arose  from  the  slipping  of  a  ligature.  The  patient 
recovered  with  no  more  serious  disturbance  than  the  great  fright. 

In  order  to  avoid  a  secondary  hemorrhage  of  this  nature  it  is  best  to  tie  all 
large  vessels  as  soon  as  they  are  divided,  especially  those  in  the  deeper  layers  of 
the  wound,  and  in  the  peritoneum.  It  is  also  well  to  sterilize  all  sloughing  areas 
over  the  iliac  vessels  by  cautiously  applying  a  little  pure  carbolic  acid,  at  once 
neutralized  by  alcohol.  Any  serious  hemorrhage  ought  to  be  controlled  tempo- 
rarily by  the  compression  of  the  internal  iliac  artery,  or  even  the  abdominal  aorta, 
until  the  arrival  of  the  surgeon,  when  the  whole  wound  must  be  opened  up  and 
cleansed,  the  bleeding  points  being  exposed  and  ligated.  Hemorrhage  from 
the  little  vessel  in  the  wall  of  the  appendix  or  from  the  cecum  can  be  obviated 
by  the  ligation  of  the  artery  of  the  mesenteriolum  down  in  the  angle  near  the 
colon,  by  crushing  the  stump,  or  by  cauterizing  it. 

Suppuration  of  the  Abdominal  Wound. — In  removal  of  the  appendix,  as 
well  as  in  other  abdominal  operations  where  there  is  an  antecedent  infection,  there 
is  a  liability  to  suppuration  of  the  abdominal  incision,  which  may  seriously  dis- 
turb convalescence,  although  grave  fears  for  the  safety  of  the  patient  do  not 
arise  until  the  nature  of  the  trouble  becomes  evident.  This  disturbance  usually 
manifests  itself  in  four  or  five  days  or,  perhaps,  a  week  after  the  operation,  when 
the  patient,  who  has  been  doing  well,  or  who  has  hail  at  most  a  slight  and  inex- 
plicable rise  of  temperature  for  a  few  days,  begins  to  complain  of  a  pain,  often 
definitely  localized,  the  temperature  goes  up  to  102°  F.  or  even  higher,  and  there  is 
sometimes  a  pronounced  chill.  The  aspect  of  the  wound,  hitherto  favorable,  now 
takes  on  the  appearance  characteristic  of  a  localized  infection  with  suppuration. 
In  all  cases  with  such  a  history,  attention  should  first  be  directed  to  the  condition 
of  the  wound.  The  dressings  should  at  once  be  removed  and  the  incision 
carefully  inspected;  if  it  is  infected,  the  edges  will  be  reddish  and  pouting  from 
puffing  of  the  skin  at  some  definite  point,  or  else  all  along  the  wound;  or,  in- 
duration, slight  swelling,  or  tenderness  may  be  discovered  at  some  point  on 


Gb'4    (AUK   OF    PATIENT   AFTEB   OPERATION    AND   POST-OPERATIVE   SEQUELS!. 

palpation.  In  such  a  case  the  diagnosis  is  clear,  and  a  little  gas  should  be 
administered  as  soon  as  possible,  after  which  the  edges  of  the  incision  are 

drawn  apart  and  the  infected  area  laid  widely  open,  cleansed,  drained,  and 
then  allowed  to  heal  by  granulation. 

Gas  Formation. — II.  I,.  Burrell  (Bost.Med.  <n>d  Sun/.  Jour.,  May  2,  1894) 
reports  three  instances  of  this  condition,  in  which,  on  the  tenth  or  twelfth  day 

after  removal  of  the  appendix,  and  after  tin'  temperature  hail  become  normal, 

its  sudden  and  continuous  rise,  accompanied  by  chills,  obliged  him  to  open  the 
wound.  ( )n  separating  the  intestines,  the  escape  of  a  large  quantity  of  gas  took 
place,  causing  a  bystander  on  one  occasion  to  remark  that  there  must  lie  a  per- 
foration of  the  bowel.  No  opening  was  found,  however,  and  in  every  case  the 
temperature  fell  to  normal  as  soon  as  the  wound  was  packed,  the  patient  making 
a  complete  recovery.  In  the  absence  of  other  reports  of  a  similar  post-operative 
sequela,  it  must  he  concluded  that  some  special  local  cause  temporarily  associ- 
ated with  the  operator  had  been  at  work  in  these  eases. 

Gangrene  of  the  Wound.  — In  badly  infected  cases,  contamination  of  the 
wound  at  the  time  of  the  operation  may  result  in  gangrene,  affecting  the  exposed 
muscles,  the  fat,  and  the  skin;    it   is  manifested  by  redness,  infiltration,  fever, 

local  pain,  odor,  and  the  appearance  of  sloughs.  The  proper  management  of 
such  a  condition  consists  in  the  freest  possible  exposure  of  the  entire  affected 
ana,  and  its  daily  treatment  by  cutting  away  the  dead  tissues,  cleansing 
with  peroxide  of  hydrogen,  and  disinfecting  the  area  with  a  poultice  of  l.abar- 
raque's  solution  (sodium  carbonate  10,  chlorinated  lime  8,  water  to  100;  made 
up  with  flaxseed  meal  or  corrosive  sublimate  1  ;  1000).  Instead  of  this,  or 
alternating  with  it,  a  charcoal  poultice  may  be  applied. 

Abscess.— Sometimes,  but  fortunately  in  rare  instances,  a  small  localized 
suppuration  will  take  place  in  or  about  the  head  of  the  cecum,  which,  becoming 
encapsulated  by  adhesions  and  an  adherent  omentum,  remains  indefinitely  in 
situ,  giving  rise  to  pain  and  local  discomfort,  which  are  apt,  sooner  or  later,  to 
necessitate  a  secondary  incision.  A  suppuration  within  the  peritoneal  cavity 
may  also  be  lodged  in  some  other  part  of  the  peritoneum,  as,  for  example,  in 
the  right  lumbar  region,  in  the  pelvis,  or  among  the  intestines.  Suppurations 
at  a  distance  from  the  wound,  although  discovered  at  some  date  subsequent  to 
the  operation,  are  not  properly  to  be  classed  among  the  sequelae  dependent  upon 
the  operation  itself.  We  shall,  therefore,  consider  only  the  local  suppurations  in 
contiguity  with  the  wound. 

Sometimes  an  infection  starting  in  the  neighborhood  of  the  amputated  appen- 
dix or  under  the  cecum  develops  slowly  and  becomes  completely  walled  in, 
giving  rise  to  symptoms  of  infection  and  local  discomfort,  more  or  less  resembling 
the  original  attack  of  appendicitis.  Such  a  case  occurred  in  the  practice  of  T.  S. 
Ci  i.i.kx  (New  York  Med.  Jour..  1902,  pi.  1111.     See  Figs.  348  and  349). 

A  boy,  fourteen  years  old.  had  a  severe  fall,  followed  some  days  later  by  an  acute 


ABSCESS    IN    VICINITY    OF    APPENDIX. 


665 


appendicitis.  The  appendix  was  removed  and  an  abscess  drained,  but  a  week 
later  there  was  an  elevation  of  temperature,  and  on  taking  out  some  of  the  stitches 
nearly  half  a  pint  of  pus  was  discharged.  In  eight  weeks  the  patient  was  about 
again,  and  for  two  years  remained  fairly  well ;  at  the  end  of  that  time  a  boy  fell  across 
him,  causing  a  return  of  the  pain  in  the  right  iliac  fossa.  Shortly  after  this  accident 
he  fell  out  of  a  boat,  and  was  again  seized  with  pain,  after  which  he  was  confined  to 
bed,  and  his  temperature  ranged  from  102°  to  104°  F.     When  seen,  ten  days  after 


Fig.  34S. — Collen's  Case.     The  Appendix  had  been  Removed  Two  Years  before. 
At  the  second  operation  the  omentum  was  found  adherent  over  the  outside  of  the  cecum,  and  behind  this  lay 

the  small  abscess  (a). 


this  last  attack,  an  area  of  induration  could  be  recognized  on  deep  palpation  just  to 
the  outer  side  of  the  sear.  At  the  operation,  on  the  next  day,  the  scar  was  dissected 
out,  and  the  convex  lower  end  of  the  cecum  exposed.  The  stump  of  the  appendix 
was  found  in  perfect  condition  and  free  from  adhesions,  but  at  a  point  about  two 
inches  above  it,  the  cecum  with  a  small  portion  of  the  omentum,  was  attached  to 
the  abdominal  wall  by  a  few  adhesions.  On  gently  pushing  back  the  omental  adhe- 
sions from  the  cecum  and  the  lateral  abdominal  wall,  a  drop  of  pus  made  its  appear- 


666    CARE   OF    PATIENT    \lTi:if    OPERATION     Wl>    POST-OPERATIVE   SEQUELiE. 

ance.  This  region  was  at  once  carefully  walled  off  from  the  surrounding  intestine  by 
a  gauze  pack,  and  a  pockel  containing  fully  100  <•<•.  of  thick,  creamy,  yellow,  offensive 
pus  was  then  evacuated.     The  abscess  cavity,  which  lay  between  the  lower  surface  of 

the  cecum  and   the  parietal    peril urn.  was   loosely  packed  with  iodoform   gauze, 

while  the  intestines  were  shut  off  in  the  same  way.  The  temperature  soon  dropped 
in  normal,  and  recover}  was  uneventful,  the  wound  closing  in  about  four  weeks.  The 
origin  of  this  abscess  was  probably  a  minute  pus  pocket  behind  tin'  cecum,  overlooked 


Fig.  349. — Same  as  Preceding.  Showing  Aun  kss  (x)  Exposed  behind  Cecuk 


at  the  original  operation  ;  the  tissues  had  been  able  to  take  care  of  so  small  a  purulent 
focus  until  repeated  injuries  ruptured  the  walls  and  aided  its  further  extension. 

In  a  ease  of  my  own,  the  removal  of  a  very  adherent  appendix,  in  which 
there  was  no  trace  of  infection,  associated  with  an  extensive  ami  difficult  enucle- 
ation of  adherent  pelvic  viscera,  was  followed  by  the  development  of  a  localized 
infection  behind  the  cecum.  The  abscess  was  promptly  opened,  when  it  dis- 
charged about  30  cc.  of  a  milky,  watery  fluid.  There  was  no  general  peritoneal 
infection,  but  the  patient  died  subsequently  from  obstruction,  due  to  general 


PYELITIS   AND   CYSTITIS.  067 

adhesions  anions;  the  small  intestines,  which  had  been  associated  with  inflamed 
pelvic  viscera. 

Epididymitis. — A.  Worcester,  of  Waltham,  Mass.  (Boston  Med.  and  Surg. 
Jour..  Aug.  4.  1898), gives  a  case  of  epididymitis  in  a  boy  ten  years  of  age,  which 
supervened  alter  the  opening  of  an  abscess  in  the  right  iliac  fossa  and  in  which 
several  ounces  of  thick  pus  escaped  and  a  sloughing  mass  was  found  which  re- 
sembled the  appendix. 

Cancer  in  the  Wound. — Richardson  and  Brewster  cite  a  case  of  cancerous 
infiltration  of  the  whole  ileocecal  region,  occurring  a  few  months  after  the  removal 
of  a  chronically  inflamed  appendix  at  the  Massachusetts  General  Hospital 
(Bost.  Med.  and  Stir g.  Jour..  July.  1898).  It  is  probable  that  a  small  cancerous 
appendix  had  here  given  rise  to  an  earl}'  perforation  with  extension  of  the  disease 
beyond  the  organ  removed,  and  that  its  true  nature  was  overlooked.  Such 
a  case  has  been  discovered  in  the  pathological  laboratory  of  the  Johns  Hopkins 
Hospital  by  E.  Hurdox. 

Pyelitis. — I  have  seen  one  instance  of  infection  of  the  right  kidney  as  a 
sequela  to  an  operation  upon  an  inflamed  appendix,  and  this  was  the  case  of 
a  physician  whose  appendix  was  removed  at  another  clinic  in  June.  1900.  His 
bladder  and  upper  urinary  tract  were  apparently  infected  by  the  attendant 
who  catheterized  him.  and  a  persistent  pyelitis  followed.  This  was  not  re- 
lieved until  I  did  a  nephrotomy  and  drained  the  kidney  on  the  fifth  of  July, 
1900,  an  operation  which  was  followed  in  a  few  weeks  by  a  complete  and  per- 
manent recovery.  Willy  Meyer  (Med.  Rec,  Feb.  29,  1896)  reports  the  case  of 
a  young  woman  who,  "after  complaining  of  pain  in  the  right  groin  for  eight  days, 
developed  symptoms  of  a  most  acute  peritonitis."  At  operation,  the  appendix 
showed  an  acute  catarrhal  inflammation,  but  no  gangrene  or  perforation,  as 
had  been  fully  expected;  neither  was  there  a  fecal  concretion  nor  any  adhesions, 
but  the  neighboring  peritoneum  was  highly  hyperemic  and  the  true  pelvis  con- 
tained sero-purulent  fluid.  The  wound  was  left  widely  open  for  drainage,  and 
the  patient  hovered  between  life  and  death  for  five  days  with  symptoms  of 
acute  sepsis.  On  the  twentieth  day  after  the  operation,  when  her  temperature 
and  pulse  for  the  first  time  were  normal,  fever  set  in  with  pain  in  the  left  renal 
region,  and  the  urine,  which  up  to  this  time  had  been  slightly  turbid,  suddenly 
became  clear.  A  diagnosis  was  made  of  obstruction  of  the  ureter  by  pus  ami 
clotted  blood,  due  to  an  abscess  of  one  of  the  pyramids  of  the  kidney.  The 
difficulty  was  suddenly  relieved  by  the  reappearance  in  the  urine  of  a  heavy, 
bloody,  purulent  deposit.  Three  weeks  later  the  urine  was  normal,  ami  the 
patient   recovered. 

Cystitis. — Inflammation  of  the  bladder,  due  to  neglect  in  allowing  overdisten- 
tion,  or  to  defective  catheterization,  or  often  in  spite  of  every  precaution,  is  a 
frequent  sequela  to  operations  of  all  sorts,  including  appendicitis.  Cystitis  would 
be  discovered  more  often  than  it  is,  if  cultures  were  habitually  taken  whenever 
the  patient  makes  the  least  complaint  of  dysuria,  but,  as  it  is,  the  lesser  grades 


668    CARE   OF   PATIENT  AFI"Eli   OPERATION   AND   POST-OPERATIVE   SEQl'KL.E. 

of  disturbance  of  the  urinary  system  arc  rarely  observed,  owing  to  the  general 
neglect  oi  this  practice.  In  my  private  hospital  it  is  my  invariable  custom 
to  draw  a  little  urine  when  the  patient  is  brought  on  the  operating  table,  and 

make  cultures  from  it.  In  this  way  the  presence  of  infection  is  often  demon- 
strated before  operation.  Dysuria,  and  perhaps  cystitis,  will  be  noted  much 
less  frequently  in  the  convalescence,  if  the  practice  is  generally  followed  of 
administering  a  saline  enema  in  all  simple  cases,  while  the  patient  is  still  upon 
the  opera  ling  table.  Some  surgeons  prefer,  instead  of  this,  to  give  urotropin 
beforehand  in  live  or  ten  grain  doses  three  times  a  day. 

Auto-infection  (Acetonemia). — (!.  E.  Brewer  lias  reported  a  fatal  ace- 
tonemia following  an  operation  for  acute  appendicitis  i.l/w<.  Surg.,  Oct.,  1902). 
Acetonemia  is  a  form  of  auto-intoxication  characterized  by  a  well-marked  sweet- 
ish odor  of  the  breath,  by  delirium,  and  by  a  rapidly  fatal  coma.  The  odor,  which 
is  sometimes  faint  and  scarcely  appreciable,  and  in  other  cases  strong  enough 
in  till  the  room,  is  that  of  acetone,  and  i<  compared  by  some  persons  to  a  pippin 
apple,  and  by  others  to  chloroform.  Acetonuria  was  at  first  recognized  only 
in  fatal  cases  of  diabetes,  1  * nt  has  now  Keen  shown  to  occur  in  i  n  f  e  C  t  i  0  U  S 
f  e  v  e  r  s  .  in  g  e  n  e  r  a  1  sepsis,  in  intestinal  f  e  r  m  entation, 
and  in  p  u  t  refactions,  etc.  Acetonemia  constitutes  a  form  of  acid  intox- 
ication, or  "acidosis,"  which  results  in  a  marked  diminution  in  the  alkalinity 
of  the  blood,  diminishing  its  power  of  absorbing  carbon  dioxide  from  the  tissues, 
SO  that  the  clinical  signs  are  due  to  a  carbonic  acid  poisoning  as  well  as  to  the 
acetonemia. 

In  Brewer's  case  the  patient,  a  school-hoy  twelve  years  of  age,  had  a  perforated, 
gangrenous  appendix,  surrounded  by  a  small  abscess  cavity  containing  but  a  few 
cubic  centimetres  of  foul-smelling  pus.  The  appendix  was  removed,  the  cavity 
disinfected,  and  two  cigarette  drains  inserted;  the  duration  of  the  anesthesia  w#s 
only  about  twenty  minutes.  <  >n  the  third  daw  the  temperature  was  normal,  the 
pulse  seventy-six,  and  the  patient  was  cheerful,  free  from  pain,  and  hungry.  The 
bowels  moved  well  and  much  gas  was  expelled.  The  urine,  which  was  normal  be- 
fore operation,  showed  afterward  a  slight  trace  of  albumen,  with  finely  granular  and 
hyaline  casts;  there  was  no  sugar.  The  third  night  after  the  operation  the  patient 
slept  quietly  until  shortly  after  midnight,  when  he  awoke  with  a  piercing  shriek, 
in  agonizing  terror.  This  condition  continued  at  intervals,  with  profound  sleep 
intervening,  until  death  occurred,  a  little  over  twenty-four  hours  later.  The  tem- 
perature was  not  elevated,  nor  was  the  pulse  quickened,  the  abdomen  was  soft,  there 
was  no  distention,  and  the  excretion  of  urine  was  free.  When  Brewer  wakened  him, 
he  "uttered  an  agonizing  cry  and  looked  the  picture  of  abject  terror.  His  eyes 
wandered  from  one  person  to  another  without  the  slightest  sign  of  recognition.  He 
continued  to  scream  with  such  vehemence  that  his  cries  were  heard  all  over  the 
building.  All  efforts  to  soothe  him  were  unavailing;  his  terror  was  painful  to  witness, 
and  the  whole  picture  suggested  unspeakable  fright,  with  the  most  acute  mental 
suffering.  These  paroxysms  would  last  from  a  few  seconds  to  two  or  three  minutes, 
and  would  be  succeeded  by  a  comparatively  long  interval  of  rest,  during  which  he 


NERVOUS    SKQUEL.E.  669 

would  apparently  be  sleeping  quietly."  In  a  short  time  a  peculiar,  sweetish,  ethereal 
odor  of  the  breath  was  noticed,  and  acetonemia  suspected.  Examination  of  the 
blood  and  urine  showed  the  presence  of  large  quantities  of  acetone  and  diacetic  acid 
in  both.     He  died  the  following  morning  in  coma. 

The  treatment  employed  was  the  rational  one  of  the  abstraction  of  400  cc. 
of  blood  followed  by  the  infusion  of  1000  cc.  of  normal  salt  solution,  containing 
about  15  gm.  of  pure  bicarbonate  of  sodium,  in  addition  to  purgatives  by  the 
mouth  and  saline  irrigation  by  the  rectum.  Brewer  gives  the  following  test 
for  acetone:  Place  about  20  cc.  of  the  urine  in  a  small  glass  retort,  heat  over  an 
alcohol  flame,  and  condense  the  vapor  in  a  test-tube;  then  add  a  small  amount 
of  potassium  hydrate  to  render  reaction  alkaline,  after  which  add  four  or  five 
drops  of  Gram's  solution  of  iodopotassic  iodide,  and  heat  gently.  If  acetone 
is  present,  a  strong  iodoform  odor  will  be  perceived,  and  yellow  crystals  will 
form  in  the  tube. 

Nervous  Sequelae. — The  nervous  sequela'  following  an  operation  for  appendic- 
itis do  not  differ  in  any  way  from  those  attending  other  grave  operations.  They 
vary  in  character  and  are  more  or  less  intense,  according  to  the  temperament 
of  the  individual  and  the  gravity  of  the  disease.  Profound  nervous  disturbances 
are  apt  to  arise  after  previous  exhaustion  from  a  protracted  illness,  or  where  there 
has  been  undue  excitement  at  the  prospect  of  surgical  interference;  and  when 
the  shock  of  a  grave  operation  is  added  to  these  factors,  we  need  seek  no  further 
to  discover  adequate  cause  for  nervous  sequelae.  Something  can  be  done  in  the 
way  of  prophylaxis  to  obviate  these  most  distressing  conditions,  by  calming  the 
patient  beforehand,  gaining  his  confidence  in  his  physician  and  surgeon,  and 
avoiding  detailed  and  picturesque  descriptions  of  the  necessary  surgical  pro- 
cedures in  his  presence.  Whenever  possible,  the  anesthetic  should  be  gently  and 
quietly  given,  with  the  full  consent  of  the  patient,  and  should  be  administered  in 
his  own  bed  or  in  a  room  adjoining  the  operating  room,  entirely  undisturbed  by 
the  bustling  preparations  for  the  operation.  It  is  better  to  defer  the  proceedings 
than  to  begin  the  anesthesia  under  compulsion  and  against  struggles.  I  would 
also  insist  on  the  importance  of  making  the  anesthesia  as  brief  as  possible  in 
cases  where  the  patient  shows  marked  signs  of  nervousness.  Much  can  also  be 
done  in  the  way  of  prophylaxis  during  the  early  convalescence  by  relieving  pain 
and  securing  some  hours  of  refreshing  sleep  during  the  twenty-four  by  the  ad- 
ministration of  hyoscyamus  (one-fiftieth  of  a  grain)  or  even  a  little  morphine 
hypodermically. 

Mental  disturbances  have  been  reported,  varying  in  degree  from  a  slight 
transient  confusion  to  violent  mania,  as  in  a  case  reported  by  G.  G.  Cott.ym  (St. 
Louis  Mai.  Rev.,  Sept.  1">.  1894).  The  patient,  a  farmer's  wife,  thirty-seven 
years  old.  had  an  appendix  removed,  which  was  incarcerated  by  bands  of  organ- 
ized lymph,  and  on  account  of  the  extensive  handling  of  the  tissues  a  gauze  dram 
was  left  in.     On  the  third  day.  after  moderate  elevation  of  temperature  and 


670    CARE   OF   PATIENT   APTEB   OPERATION    AND    POST-OPERATIVE   SKtjl  i:i.  1 :. 

increase  of  pulse,  "  acute  maniacal  delirium  with  high  temperature  abruptly  fol- 
lowed, the  patient  making  frantic  attempts  to  bite,  scratch,  kick,  and  otherwise 
injure  those  who  tried  to  restrain  her. "  Death  shortly  closed  the  scene.  W  II. 
Doughty,  of  Augusta,  Ga.,  related  to  me  the  ease  of  a  delicate  girl  about  six- 
teen years  of  age,  who  had  been  hard  worked  at  school,  was  nervous,  worried,  and 
cried  easily.  At  the  operation  for  an  acute  appendicitis  the  appendix  was  found 
swollen,  but  not  perforated,  with  a  few  drops  of  pus  on  its  outside.  The  wound 
was  drained,  and  the  patient  did  perfectly  well  for  three  days,  bavingno  fever, 
when  suddenly  at  two  o'clock  in  the  night,  sixty  hours  alter  the  operation,  she 
awoke  screaming,  and  in  a  violent  mania,  which  continued  until  her  death  I'orty- 
eighl  hours  later.  Her  pulse  rose  to  160  and  her  temperature  to  105°  F.;  she 
hit  her  mother  on  the  cheek,  ami  fought  and  scratched  all  who  came  in  contact 
with  her.  No  peritonitis  was  found  at  the  postmortem  ami  the  area  of  the 
wound  was  perfectly  walled  off  by  the  gauze.     The  symptoms  of  these  two  cases 

are  exceedingly  suggestive  of  an  acetonemia,  as  observed  by  Brewer,  and   it 

is  plain  that  all  our  cases  of  mental  disturbance  and  mania  following  operation 
must  he  subjected  to  a  more  systematic  investigation  from  this  standpoint. 

A  dry  cough  or  a  h  i  c  c  o  u  g  h ,  trifling  ailments  in  themselves,  may 
cause  extreme  distress  when  associated  with  a  recent  wound,  on  account  of  the 
uncontrollable  contractions  of  the  abdominal  muscles.  Minute  doses  of  morphine 
may  he  necessary  here  to  bring  relief.  The  superficial  use  of  the  actual  cautery 
over  the  epigastrium  will  often  stop  the  hiccough,  and  a  mustard  plaster  over 
the  chest  will  sometimes  relieve  the  cough.  In  a  hail  case  it  is  a  good  plan  to 
give  inhalations  of  the  compound  tincture  of  benzoin,  prepared  by  pouring  a  pint 
of  boiling  water  on  a  drachm  of  the  drug;  the  vapor  from  this  is  then  inhaled 
through  a  funnel-shaped  tube;   tincture  of  opium  may  he  added  to  it. 

Bronchial  Catarrh. — A  bronchial  catarrh  is  bestavoided  by  operating  in  a 
warm  room,  and  by  keeping  the  patient  warm  during  the  preliminary  prepara- 
tions, as  well  as  during  the  operation.  As  little  anesthetic  as  possible  should 
he  given,  especially  if  ether  is  used.  When  the  condition  occurs,  the  envelop- 
ment of  the  chest  in  an  extensive  mustard  plaster  has  been  found  an  effective 
agent    in    relief. 

Pleuritis. — A  pleuritis  is  usually  a  sequela  to  the  graver  forms  of  appendic- 
itis, such  as  the  perforative  and  the  gangrenous.  It  may  vary  in  degree  from 
a  light  transient  form,  recognized  only  by  the  pain  and  a  slight  friction  sound, 
to  an  extensive  exudate  filling  the  right  chest  and  compressing  the  lung,  which 
ultimately  becomes  purulent  and  emits  a  foul  fecal  odor  due  to  the  colon  bacillus. 
The  severer  forms  of  pleuritis  are  often  associated  with  other  suppurative  foci 
within  the  abdomen.  Pleuritis  of  this  description  has  been  particularly  studied 
by  h.  Lapeyre  (Rev.  de  chir.,  19Q1,  torn.  '2'.]),  who,  following  Dieulafoy,  recog- 
nizes two  absolutely  distinct  forms  of  pleurisy,  one  the  result  of  pyemic  infection 
in  which  the  infecting  organisms  enter  the  circulation  by  the  vein,  and  form 
embolic  infarcts  which  reach  the  pleura,  as  they  reach  the  lungs,  the  muscles, 


PLETJRITIS.  C71 

the  kidneys,  and  the  brain.  This  variety  is  very  rare,  and  has  no  clinical  or 
therapeutic  interest.     The  second  form,  which  is  distinctively  an  appendical 

pleurisy,  is  simply  an  abscess  of  the  pleura  resulting  from  the  focus  of  infection, 
the  appendix.  The  pyemic  form  occurs  with  equal  frequency  on  either  side, 
but  the  appendical  form  is  always  found  in  the  right  pleura.  Lapeyke  insists 
that  appendical  pleurisy  is  always  preceded  or  accompanied  by  a  focus  of 
suppuration  under  the  diaphragm  (subphrenic  abscess)  of  which  it  is  but  the 
terminus.  He  lays  great  stress  upon  this  fact,  and  holds  that  the  theory  of  a 
propagation  of  the  pleurisy  from  a  septic  focus  at  a  distance  by  means  of  a  sup- 
purative lymphangitis,  as  described  by  Piard  and  DlEULAFOY,  must  now,  in 
view  of  many  clinical  facts,  be  given  up  ("elle  .  .  .  mine  la  Iheorie  de  la 
pleurisie  h  distance  par  lymphangite  pleuro-parietale"). 

The  symptoms  of  a  right-sided  pleurisy  are:  fever,  quickened  pulse, 
rapid  respiration,  and,  often,  pronounced  sweats,  with  sticking  or  stabbing 
pain  in  the  lower  thorax,  or  at  a  point  near  the  shoulder-blade;  there  are  friction 
sounds  in  the  early  stages,  and  later  on,  dulness  on  percussion,  extending 
gradually  upward,  even  as  high  as  the  fourth  interspace;  the  liver  is  frequently 
pushed  down,  there  is  tenderness  on  pressure  over  the  thorax,  and  sometimes 
edema  of  the  chest  walls.  A  hollow  needle  may  be  used  to  make  the  diagnosis 
certain.  It  is  important  in  all  such  cases  to  bear  in  mind  the  likelihood  of 
suppuration  within  the  abdomen,  sometimes  in  the  neighborhood  of  the 
ascending  colon,  sometimes  under  the  liver,  and  almost  always  above  the  liver 
and  below  the  diaphragm.  The  intra-abdominal  focus  of  infection  is  sometimes 
so  completely  masked  by  the  extensive  pleuritic  effusion  that  the  surgeon  may 
wholly  fail  to  recognize  the  source  of  a  purulent  pleurisy  until  he  has  opened 
and  evacuated  it.  It  has  happened  in  a  number  of  instances,  especially  in 
children,  that  an  appendicitis  has  been  recognized  for  the  first  time  after  open- 
ing the  chest  to  evacuate  the  pleura. 

Treat  m  e  n  t  . — The  best  prophylactic  treatment  consists  in  the  free 
drainage  of  the  retrocolic  abscess,  or  in  the  early  recognition  and  drainage  of  a 
subdiaphragmatic  abscess.  In  the  event  of  the  formation  of  a  pyemia  of  the 
pleura,  the  surgeon  should  take  prompt  steps  to  secure  good  drainage.  If  the 
accumulation  is  a  small  one,  an  opening  may  be  made  in  the  intercostal  space  in 
front  of  the  posterior  axillary  fold,  between  the  seventh  and  eighth,  or  the 
eighth  and  ninth  ribs,  a  little  external  to  the  angle  of  the  scapula.  The  incision 
should  be  about  two  inches  long,  just  above  the  rib.  When  the  pleura  i-  opened, 
it  should  be  thoroughly  washed  out.  wiped  as  far  as  accessible,  and  then  drained. 

In  cases  in  which  the  collection  in  the  pleura  is  serous  in  nature,  entire  relief 
may  follow  a  simple  aspiration.  Where  there  is  a  considerable  collection  of  pus, 
the  better  plan  is  to  resort  at  once  to  the  resection  of  a  rib:  this  proceeding  gives 
abundant  room  to  explore,  to  cleanse,  and  to  drain  the  infected  space.  As 
the  resection  is  done  under  the  periosteum,  the  intercostal  vessels  and  nerves 
are  not  injured,  and  the  integrity  of  the  rib  is  restored  after  the  necessity  for 


ti72    CARE  OF  PATIENT   AFTER   OPERATION   AND   POST-OPERATIVE   BEQUELiE. 

drainage  is  done  away  with.  An  incision  is  made  over  the  ninth  rib,  rather 
posteriorly,  in  order  to  secure  good  drainage,  as  the  patient  lies  in  bed.  The 
costal  periosteum  is  then  divided,  elevated,  and  peeled  back  From  the  bone  on 
all  sides,  the  grooveal  the  posterior  inferior  surface  being  included.  After  com- 
pleting the  periosteal  detachment,  the  denuded  bone  is  removed  with  bone  pliers 
or  a  small  chain  saw.  When  the  pleura  are  exposed,  a  hypodermic  syringe  may  he 
used  to  locate  the  pus.  which  is  then  drained  off  slowly  through  a  small  opening,  SO 

as  to  avoid  syncope.  The  empty  cavity  should  now  he  washed  thoroughly  clean 
of  pus  and  lymph,  greal  care  being  taken  not  to  use  undue  pressure  in  irrigating. 
The  next  step  is  to  introduce  a  good-sized  rubber  drainage-tube,  which  is  kepi  from 
slipping  out  by  sewing  it  to  the  skin  with  a  couple  of  silk  sutures.  The  wound  is 
then  swathed  in  handfuls  of  loose  gauze  handkerchiefs,  kept  in  place  by  straps 
and  a  bandage.  As  the  cavity  closes  and  the  discharge  grows  less,  the  con- 
dition of  the  patient  improves.  If  the  drainage  is  not  satisfactory,  a  counter- 
opening  may  he  made  at  a  more  dependent  point,  between  the  two  ribs,  by 
carrying  an  instrument  into  the  original  opening  and  using  it  to  push  the  pleura 
forward  while  the  operator  cuts  down  on  its  point.  A  rubber  drainage  tube  may 
then  he  inserted  from  one  opening  to  the  other.  This  secondary  operation  can 
be  done  under  cocain  anesthesia. 

Lung  Complications. — The  subject  of  lung  complications  following  opera- 
tions for  appendicitis  is  one  of  peculiar  interest  to  the  pathologist  as  well  as  to 
the  clinician,  and  to  the  surgeon.  Interest  in  it  began  with  the  studies  of  the 
phenomena  leading  to  the  formation  of  a  thrombus  in  intravascular  coagulation; 
phenomena  closely  associated  with  the  names  of  VlRCHOW,  who  attributed  the 
greatest  importance  in  the  process  to  the  retardation  of  the  blood-current,  and  of 
BRUCKE,  who  drew  especial  attention  to  the  alterations  taking  place  in  the  walls 
of  the  vessels;  the  interest  being  further  sustained  by  the  studies  of  Cohnheim  and 
of  Eberth-Schimmelbusch  on  the  organization  of  the  thrombus.  From  throm- 
bus to  embolus  is  a  natural  sequence.  Gerhardt  showed  the  character  of  tic 
hemorrhagic  infarct  in  a  paper  entitled  "  Der  hamorragische  Infarkt"  (Volk- 
mann's  Samml.  kl.  Vortr.  j.  inn.  Med.,  No.  31).  Gussenbaueh  demonstrated 
that  the  pneumonias  so  often  observed  after  the  release  of  an  incarcerated  her- 
nia were  always  embolic  in  origin.  It  has  only  recently  been  shown,  however, 
that  the  pneumonias,  and  also  many  of  the  pleurisies,  following  abdominal 
operations  of  all  kinds  are  due  to  thrombosis  and  embolism.  For  a  complete 
exposition  of  the  subject  see  Welch's  article  in  Allbutt's  System  <>j  Medicine. 
A  valuable  article  has  also  been  written  by  A.  OPPENHEIM,  utilizing  SoN- 
NENBURG's  material,  entitled  "  Luni/enrmholien  naeh  chiriirc/ischen  Kimjrijjen 
mil  besonderer  Berucksichtigung  der  naeh  Operationen  am  Processus  Vermiform  is 
beobachteten"  {Bed.  klin.  Woch.,  Feb.  3,  1902,  p.  94). 

Freq  uency. — In  a  study  of  1000  cases  of  appendicitis,  Sonnexburg 
found  lung  complications  in  5  per  cent.  (Archie  j.  klin.  Chir..  1902,  Bd.  68,  p. 
468).     All  of  these  cases  were  in  the  public  hospital  at  Moabit,  and  in  this  group 


PULMONARY    EMBOLISM.  673 

thrombosis  and  embolism  were  observed  17  times,  while  in  200  eases  occurring 
in  Sonnenbubg's  private  hospital  the  same  complications  occurred  19  times. 
According  to  him,  the  discrepancy  between  the  two  sets  of  figures  i-  due  to  the 
difference  in  the  class  of  patients  treated  in  the  two  hospitals. 

Etiology  . — A  pulmonary  embolus  following  an  operation  on  the  vermi- 
form appendix  is  a  sequela  to  a  thrombus  previously  formed  in  the  pelvic  or 
femoral  veins.  Small  emboli  may  form  in  the  vessels  of  Retzius  which  traverse  the 
outer  surface  of  the  cecum  and  enter  the  lumbar  veins;  it  is  also  possible  for  an 
embolus  to  pass  into  the  heart  by  the  portal  anastomosis  with  the  cava.  For  prac- 
tical purposes,  however,  the  sole  source  of  pulmonary  emboli  lies  in  the  tribu- 
taries of  the  common  iliac  veins.  The  pathologic  chain,  whose  last  link  is  the 
pulmonary  arterial  branches  of  the  lung,  consists  of  the  following  individual 
links :  an  appendicitis,  an  operation,  the  f  o  r  m  a  t  i  o  n  of 
a  thro  m  bus  in  the  adjacent  veins,  the  detachment  of 
the  thrombus,  its  j  o  u  r  n  e  y  t  hrough  the  i  1  i  a  c  v  e  i  n  8 
a  n  d  u p  w  a  r d  t  h r  o ugh  the  vena  c  a  v a  into  t  h  e  right 
heart,  its  transit  through  the  auricle  a  n  d  ventri- 
cle into  one  of  the  pulmonary  arteries  out  into 
the  lung,  where  it  lodges  as  an  embolus  which  gives 
rise  to  a  hem  o  r  r  h  a  g  i  c  p  u  1  m  o  n  a  r  y  infarct.  Cases  of 
embolism  without  operation  are  almost,  if  not  quite,  unknown. 

Symptoms  . — The  attack  comes  on  in  one  to  four  weeks  after  the  opera- 
tion, and  it  may  come  on  when  the  patient  is  first  up  and  about,  being  espe- 
cially apt  to  occur  during  some  act  of  exertion,  especially  straining  at  stool.  The 
patient  feels  a  severe  pain  in  the  pelvis  due  to  the  detachment  of  the  thrombus, 
or  in  the  back  or  shoulder  from  the  lodgment  of  the  embolus.  The  pulmonary 
pain  then  increases  in  intensity,  and  there  is  evidence  of  air  hunger,  the 
patient  becoming  cyanotic  or  lead-colored,  while  the  respiration  is  embarrassed 
and  rapid.  There  is  great  mental  distress  and  apprehension  with  profuse  sweat- 
ing and  sometimes  vomiting,  the  heart  becomes  feeble  and  irregular  in  action, 
and  the  pulse  is  small  and  quickened  to  as  much  as  140  a  minute,  or,  it  may  be, 
disappears  altogether.  As  a  rule,  there  is  slight  elevation  of  temperature, 
but  the  fever  is  not  usually  high  and  never  runs  the  course  of  an  ordinary  pneu- 
monia. There  is  pain  in  breathing  and  a  slight  pleuritic  exudate  may  be  noted. 
After  a  day  or  two,  when  the  infarct  has  formed,  there  is  characteristic  bloody 
sputum,  a  few  cubic  centimetres  at  a  time.  The  thorax  is  sometimes  excessively 
sensitive,  even  to  the  stethoscope,  which  reveals  rales  and  an  absence  of  the 
regular  respiratory  sounds. 

Diagnosis. — A  pulmonary  embolism  may  be  mistaken  for  a  pleurisy 
on  account  of  the  intense  stabbing  pain  in  the  chest,  associated  with  embarrassed 
respiration,  and  a  moderate  elevation  of  the  temperature.  There  can  be  no 
doubt,  as  shown  by  G.  B.  Miller  (Amer.  Med..  1902,  vol.  1.  p.  1.73),  (  h  a  t 
most  of  the  so-called  pleurisies  which  folio  w  a  b  - 
43 


('.71    CARE   OF   PATIENT   AI  IKK   OPERATION    AND   POST-OPERATIVE   SEQUEIuE. 

(luminal  operations  arc  due  to  emboli  of  medium 
size.  The  diagnosis  of  an  embolus,  however,  can  be  made  by  noting  the  car- 
diac embarrassment,  the  quickened  respiration  and  pulse,  with  slightly  in- 
creased dulness  on  percussion,  and,  later,  signs  of  hepatization.  The  fever,  as 
staled,  is  slight,  and  never  pneumonic  in  type.  The  characteristic  bloody 
sputum  from  the  infarct  appears  in  twenty-four  hours.  Slight  attacks  are  often 
recognized  by  their  tendency  to  repetition.  There  is  no  doubt  that  if  close 
attention  is  paid  to  all  complaints  referred  to  the  thorax,  the  diagnosis  of 
embolism  will  he  made  much  more  often  in  the  future. 

Trea  t  men  t  . — Much  may  undoubtedly  he  done  in  the  way  of  prophy- 
laxis by  avoiding  all  injury  to  the  pelvic  veins  in  the  course  of  the  operation  on 
the  appendix.  If  an  adherent  appendix  crosses  the  iliac  vein,  it  will  often  he 
better  to  strip  the  inner  coats  of  the  appendix  out  of  the  outer  coats,  so  as  to 
avoid  injuring  the  vein.  Especial  care  must  he  taken  to  avoid  the  formation 
of  the  parent  thrombus;  if.  however,  a  thrombus  is  known  to  have  formed, 
all  active  exertion  or  straining,  especially  at  stool,  musl  he  sedulously  avoided. 
\iirr  the  embolic  attack  the  patient  must  he  kept  as  nearly  as  possible  in  abso- 
lute rest,  if  necessary  with  the  head  and  shoulders  elevated.  Small  hypodermic 
doses  of  morphine  repeated  at  intervals  do  much  to  compose  the  mind  and  quiet 
the  action  of  the  heart.  As  pointed  out  long  since  by  Gerbardt,  digitalis  is 
dangerous  and  should  never  he  given.  The  responsibility  of  the  physician  is 
heightened  when  the  patient  has  had  one  attack;  he  must  then  guard  with  the 
utmost  care  against  the  slightest  exertion,  insisting  upon  complete  quiet  and 
absolute  rest  until  the  infarcts  are  absorbed  and  all  thrombi  organized  or 
absorbed.  Oxygen  should  be  administered  to  supplement  the  need  created  by 
the  diminished  area  of  aeration:  dry  cups  applied  over  the  pleura  are  valuable 
to  relieve  pain.  The  pulmonary  infarct  tends  to  heal  rapidly,  and  needs  no  other 
treatmenl  than  the  avoidance  of  infection  by  the  respiratory  channel ;  to  this  end 
care  should  be  taken  to  avoid  raising  any  dust  in  the  room,  and  on  windy  days 
to  prevent  its  entrance  from  the  outside.  As  a  rule,  general  improvement  takes 
place,  and  the  patient  passes  in  a  few  days  or  weeks  to  complete  recovery,  but 
it  is  always  possible  that  death  may  close  the  distressing  scene. 

Intestinal  Fistula. — A  fecal  fistula  is  one  of  the  commonest  sequelae  to 
an  operation  for  appendicitis,  especially  when  the  disease  has  advanced  to 
suppuration  or  gangrene.  Fowleb  observed  (i  cases  in  l(i<)  operations  on 
appendicitis  (Ann.  Surg.,  May  is.  hs()4);  Van  Lennep  gives  0  in  118 
operations.  M.  F.  Porter  noted  8  instances  of  fistula  persisting  for  four 
months  or  longer  after  incision  and  drainage,  out  of  187  operations  (Amer. 
Jour.  Mai  Sri.,  Dec.  L893).  E.  Muhsam  (Mitt.  a.  d.  Grenzgeb.  der  Med.  u. 
Cln'r..  l'.iu:;.  lid.  1 1,  284)  notes  78  cases  of  fistula  occurring  in  Sonnenburg's  prac- 
tice in  a  series  of  441  operations  for  appendicitis,  while  in  a  further  study  of  815 
cases,  immediately  following  those  just  cited,  there  were  only  54  fistulas,  showing 
a  difference  of  6.6  per  cent,  in  contrast  to  16.3;  an  improvement  of  almost  10 


INTESTINAL  FISTULA.  675 

per  cent.,  attributable  in  part  to  increasing  experience  and  greater  skill  on  the 
part  of  the  surgeon,  and  in  part  to  better  judgment  among  physicians,  who  recog- 
nize the  appendicitis  earlier  than  formerly,  and  send  their  patients  more  promptly 
for  operation.  It  should  be  noted  that  three  of  these  fistulas,  one  of  which  was 
vesical,  were  not  post-operative. 

The  fistulas  which  originate  spontaneously  through  the  discharge  of  an 
abscess  on  to  the  skin  surface  have  been  already  discussed  (Chap.  XXV,  p.  592), 
and  I  desire  to  speak  here  only  of  those  which  occur  as  sequelae  to  operation. 
Fistulas  of  this  kind  vary  from  those  which  are  extremely  minute,  secreting 
not  more  than  a  drop  or  two  per  diem  of  a  purulent  and  watery  fluid,  to  those 
with  a  freer  secretion  of  thin  fecal  matter  and  bubbling  gases;  fir,  it  may  lie, 
the  entire  alvine  evacuation,  short-circuiting  the  cecum,  escapes  by  this  route. 

The  external  opening  of  the  orifice  may  lie  single  or  multiple;  or,  occasion- 
ally, it  may  lie  cribriform.  After  traversing  the  abdominal  wall  the  fistula  may 
open  into  the  appendix  directly,  or  into  the  colon  at  the  base  of  the  appendix, 
or  into  the  colon  or  cecum  at  some  point  above  the  base,  or,  in  rare  instances, 
into  the  ileum.  Blind  fistulas  are  rarely  seen.  Sonnenbueg  mentions  a  fistula 
(not  post-operative)  in  which  a  communication  had  formed  between  the  cecum 
and  a  pocket  containing  fecal  concretions.  In  this  case  the  appendix  had 
sloughed  off,  and  left  a  perforation  opening  into  the  bowel  at  the  base  of  the  ap- 
pendix, while  the  surrounding  reactive  peritonitis  had  been  able  to  build  up  a 
wall  of  adhesions  dense  enough  to  shut  off  the  peritoneal  cavity,  as  well  as  any 
other  route  by  which  the  infectious  material  might  be  discharged.  Such  blind 
fistulas  are  occasionally  met  with  as  a  disagreeable  surprise  in  interval  operations. 

Our  surgeons  ought  to  distinguish  carefully  between  a  fistula  and  a  slow- 
healing  sinus  in  which  there  is  no  communication  with  the  bowel  at  the 
base.  A  sinus  is  nothing  but  a  pocket,  kept  from  healing  by  some  foreign  body, 
as  a  ligature  or  a  concretion,  or  by  the  devitalized  nature  of  its  walls,  while  a 
fistula  must  be  a  through-and-through  communication  between  the  intestinal 
tract  and  the  surface  of  the  body.  I  do  not  speak  here  of  fistulas  between  the 
adherent  vermiform  appendix  and  the  adjacent  cecum  or  the  ileum,  nor  of 
fistulas  opening  into  the  vagina  or  the  bladder. 

E  t  i  0 1  0  g  y. — A  fistula  rarely  follows  an  ideal  operation  in  which  the  am- 
putation of  the  appendix  has  been  made  in  sound  tissues  and  followed  by  a 
satisfactory  suturing  of  the  opening.  The  causes  of  fistula  are  most  commonly 
to  be  found  in  the  conditions  imposed  upon  the  operator  by  the  nature  of  the 
disease;  for  example,  they  occur  oftenest  when  it  has  been  possible  only  to  incise 
an  abscess,  leaving  behind,  from  necessity,  the  perforated,  sloughing,  or  gan- 
grenous appendix.  The  simplest  forms  of  fistula,  in  which  there  is  no  fecal 
discharge,  are  apt  to  occur  when  the  perforation  takes  place  either  at  the  tip 
of  the  appendix,  or  somewhere  in  its  course,  beyond  the  base.  A  fistulous  trad 
is  sometimes  kept  open  by  a  foreign  body,  such  as  a  fecal  concretion,  which 
has  escaped  from  the  appendix,  and  lies  in  the  iliac  fossa;  or  by  a  silk  ligature, 


676    CARE   OF   PATIENT    AFTEB   OPERATION    AND    POST-OPERATIVE   SKijlKn.E. 

hurriedly  applied  to  the  base  of  the  appendix  in  an  abscess  case.  In  a  case  of 
Porter's  (Amer.  Jour.  Obstet.,  1902,  p.  688)  an  abscess  had  been  incised  and 
drained,  leaving  a  sinus,  and  whenever  it  closed,  the  patient,  a  little  boy,  had  a 
fresh  attack  of  pain  only  relieved  by  its  spontaneous  reopening.  On  opening 
the  abdomen  a  large  fecal  concretion  was  found  in  an  appendix  entirely  detached 
from  the  bowel.  In  several  of  Sonnenburg's  cases  the  fistula  was  due  to  tuber- 
cular disease  of  the  appendix;  in  two  out  of  five  there  was  a  lung  affection  as  well. 
This  possibility  should  always  be  borne  in  mind  when  a  fistula,  secreting  a  thin 
fluid,  remains  persistently  open  without  apparent  cause.  A  careful  physical  ex- 
amination of  the  chest,  as  well  as  of  the  secret  ions  of  the  fistula,  may  illuminate 
the  diagnosis. 

A  fistula  is  particularly  apt  to  follow  an  excision  of  one  of  those  old  inflamed 
appendices  found  lying  behind  or  to  the  outside  of  the  cecum,  and  so  densely 
adherent  that  any  attempt  to  dig  the  organ  out  of  its  bed  is  almost  sure  to  be 
accompanied  by  the  rupture  of  the  outer  coats  of  the  bowel;  such  an  occurrence, 
possibly  not  recognized  at  the  time,  may  he  followed  by  the  sloughing  of  the  re- 
maining thin  septum,  ami  the  escape  of  the  contents  of  the  bowel.  It  is  evident 
that  the  occurrence  of  such  an  untoward  sequela,  interrupting  recovery  and  re- 
tarding convalescence,  is  always  due  to  imperfect  technic;  that  is  to  say,  to  a 
technic  which,  while  it  may  have  been  necessarily  imperfect  under  the  conditions 
imposed  upon  the  surgeon,  would  yet  have  been  better,  perhaps  even  ideal,  had 
the  patient  been  seen  before  the  existence  of  the  complications.  In  a  bad  case, 
however,  where  the  operation  is  done  upon  an  indicatio  vitalis,  the  surgeon  may 
be  well  content  if  he  saves  life,  whatever  disagreeable  concomitants  go  with  the 
purchase. 

Treatment. — Prophylaxis  is,  perhaps,  the  most  important  element  in 
the  treatment  of  fistula,  because  so  much  can  be  (lone  to  avoid  a  result  so  an- 
noying to  the  surgeon,  ami  a  source  of  great  mental  disquietude  to  the  patient. 
I'uri  passu  as  appendicitis  is  recognized  and  operated  upon  in  the  earliest 
stages  of  the  disease,  that  is  to  say,  before  the  formation  of  an  abscess,  is  fistula 
unlikely  to  occur.  As  long  as  abscess  cases,  especially  neglected  ones,  continue 
to  be  incised  ami  drained,  just  so  long  will  fistulas  continue  to  soil  the  dressings. 
KoCHER's  plan  of  making  a  separate  incision  a  few  days  after  opening  and  drain- 
ing the  abscess,  in  order  to  discover  and  remove  the  appendix,  will  lessen  the 
frequency  of  fistulas  in  the  suppurating  cases.  A  fistula  will  never  arise  in  a 
simple  case  if  fine  silk  sutures  are  used  for  the  bowel,  while  catgut  is  employed 
only  in  tying  off  the  little  mesentery.  When  the  appendix  is  simply  ligated  and 
amputated  in  an  abscess,  formalin  or  chromicized  catgut  ought  to  be  used. 
Surgeons  will  reduce  their  percentage  of  fistulas  if  they  take  great  care  to  excise 
well  into  the  sound  tissues,  anil  then  to  sew  Up  the  bowel  opening  with  mattress 
sutures,  using  fine  silk  and  a  fine  needle,  and  burying  the  wound  under  one  or 
two  layers  of  srro-serous  sutures.  I  have  never  seen  the  fine  silk  sutures  give 
rise  to  any  after-disturbance. 


INTESTINAL    FISTULA.  G77 

A  serious  form  of  fistula,  namely,  that  arising  from  the  rupture  of  the  outer 
coat  of  the  cecum  or  ascending  colon  in  the  enucleation  of  a  densely  adherent 
appendix,  will  be  avoided  by  following  the  plan  of  first  detaching  the  appendix 

from  the  bowel  at  its  base,  then  incising  the  peritoneal  and  longitudinal  muscular 
coat  along  its  dorsum,  and  finally  stripping  the  appendix  out  of  its  bed  inside  its 
circular  coat  and  with  its  mucosa,  leaving  the  bowel  untouched  (see  Chap.XXV,  p. 
576).    If  this  is  done,  a  fistula  will  rarely  ever  be  seen  after  an  interval  operation. 

In  the  case  of  a  pest-operative  fistula  of  doubtful  etiology  it  is  well  to  ex- 
plore it  with  a  little  crochet  hook,  and  if  there  is  a  ligature  at  the  bottom  to 
draw  it  out.  It  is  well  also  to  keep  all  abscess  cavities  widely  open,  and  wash 
them  out  vigorously  so  as  to  remove  any  foreign  body.  Where  the  cecal  wall 
about  the  base  of  the  appendix  seems  likely  to  break  down,  it  is  a  good  plan 
to  draw  the  omentum  down  over  the  affected  area  and  suture  it  there  at  the 
base  of  the  appendix  (Soxxenburg). 

MtiHSAM  (Mitt.  a.  d.  Grenzgeb.  der  Med.  u.  Chir.,  1900,  Bd.  5,  p.  Ill)  conve- 
niently divides  fistulas,  from  a  clinical  standpoint,  into  those  in  which  the  dis- 
charges are  purulent,  and  those  in  which  there  is  leakage  of  fecal  matter.  Of 
3.")  cases  in  which  the  discharge  was  merely  serous  or  purulent,  00  per  cent, 
recovered  spontaneously,  or  markedly  improved  while  10  were  operated  upon. 
( hit  of  40  cases  with  fecal  discharges,  38  (about  62  per  cent.)  either  healed  spon- 
taneously or  were  decidedly  improved,  S  recovered  after  operation,  and  12  died, 
3  of  the  deaths  being  among  the  patients  operated  upon.  The  causes  of  death  in 
the  12  cases  where  it  occurred  were:  three  times,  tuberculosis;  once  (probably), 
post-operative  hemorrhage;  six  times,  peritonitis,  recognized  in  part  at  the  time 
of  the  operation;   once,  ileus;   once,  progressive  weakness. 

Fistula  (even  in  aggravated  cases)  tends  to  spontaneous  recovery  in  such  a 
remarkable  way,  even,  it  may  be,  after  weeks  ami  months,  that  the  expectant 
plan  of  treatment  should  always  lie  the  first  thought  of  the  surgeon.  G.  W. 
Perkins  had  a  case  where  for  two  weeks  all  the  feces  were  discharged  by  the 
wound,  but  in  the  fourth  month  a  complete  recovery  had  taken  place.  T.  W. 
Harvey,  of  Orange,  X.  J.,  had  a  curious  case  in  which  a  fistula  closed  after  a 
few  days,  and  then  opened  again  t<>  give  exit  to  a  large  round-worm,  after  which 
it  closed  definitively.  On  the  other  hand,  a  case  of  Gage's  ran  seven  years 
and  then  recovered. 

After  an  operation  in  which  there  is  reason  to  anticipate  a 
fistula,  it  is  best  to  avoid  a  tight  pack  in  suturing  the  wound.  Mtjhsam 
praises  the  Mikulicz  tamponade,  which  consists  in  an  apron  of  gauze  inserted  at 
the  bottom  of  the  wound,  while  inside  of  this  protective  covering  is  laid  the 
drain  proper.  By  leaving  the  apron  in  place,  the  drainage  may  be  changed 
without  injury  to  the  tissues.  It  is,  further,  a  matter  of  urgent  importance  to 
avoid  interfering  with  the  delicate  granulations  which  form  and  tend  so  rapidly 
to  blockade  any  preternatural  openings;  by  such  means  alone  can  nature  cure 
the  ill;  if  these  are  repeatedly  broken  down  through  a  meddlesome  and  mistaken 


678    CARE   OF   PATIENT   AFTER   OPERATION   AND   POST-Ol'KKATIVE   SKcn'KI-K. 

zeal,  a  fistula  may  even  be  created  where  none  would  otherwise  have  occurred. 
The  first  complete  change  of  the  dressings  may  take  place  alter  live  days  or  a  week, 
as  in  other  abdominal  suppurative  conditions;  the  outer  layers  of  gauze  which  soak 
up  the  secretions  on  the  skin  surface  being  removed  constantly  in  the  meantime. 

The  patient  in  danger  of  acquiring  a  fistula  ought  to  receive  only  a  minimal 
amounl  of  food,  and  live  as  much  as  possible  on  albumen  water.  The  bowels, 
if  quiet,  should  be  opened  by  a  rectal  enema  consisting  of  a  few  ounces 
of  oil,  alter  five  or  six  days.  As  long  as  the  fistula  is  discharging,  the  wound 
should  he  kept  widely  open,  more  widely  at  the  top  than  at  the  bottom,  and 
the  surface  frequently  cleansed  by  the  attendant  applying  fresh  gauze  in  the 
form  of  loose  fluffy  napkins.  The  surrounding  skin  should  he  protected  from 
the  irritating  discharges  by  a  still'  paste  of  oxide  of  zinc  or  an  ointment  of  sali- 
cylate of  zinc.     Muhsam  recommends  a  poultice  made  with  acetate  of  aluminium. 

In  had  cases  of  fistula,  h  y  d  r  o  p  a  t  h  y  affords  a  treatment  of  the  utmost 
value,  during  their  early  stages  of  granulation.  By  this  method  the  wound  is 
kept  continually  bathed  by  the  circumambient  water  and  thus  kept  clean;  the 
closure  goes  on  with  surprising  rapidity,  and  greatly  to  the  satisfaction  of  the 
patient.  If  the  patient  can  stand  it.  he  does  best  kept  in  this  hath  for  the 
entire  day,  with  shoulders  and  chest  well  wrapped  and  protected;  a  weaker 
patient  may  remain  one  to  two  hours  at  a  time,  each  morning  and  evening. 
After  removal  from  the  hath,  a  vigorous  rub,  a  warming  drink,  ami  a  comfortable 
bed  induce  an  enviable  state  of  hicn-etrc.  In  my  private  hospital  I  have  such 
a  bath  arrangement  installed  in  a  room  adjacent  to  a  bath-room,  where  the 
supply  and  discharge  pipes  for  the  attachment  of  the  tub  when  needed,  are 
conducted  along  the  floor  under  the  wash-board;  in  the  bath-room  there  is 
a  large  gas  heater  with  a  thermostat  which  acts  upon  the  coils  of  cold-water 
pipes  by  which  the  water  is  discharged  at  a  constant  temperature  of,  say.  1(12°  F. 
in  a  slow  stream  into  the  bath-tub,  if  possible  directly  over  the  wound;  the 
outflow  going  on,  of  course,  at  the  same  rate.  By  this  means  a  continuous  temper- 
ature is  easily  maintained  ami  the  wound  has  the  advantage  of  a  constantly 
changing  water  dressing,  while  the  patient  has  the  comfortable  assurance  of 
perfect   cleanliness. 

The  closure  of  a  fistula  by  operation  may  vary  all  the  way  from  a  procedure 
which  is  comparatively  easy  (in  skilful  hands)  to  one  of  the  utmost  difficulty.  If 
there  is  more  than  one  opening  on  the  skin  surface,  it  is  best  to  do  a  preliminary 
operation  by  slitting  uptheskinso  as  to  establish  a  single  orifice  which  leads 
directly  to  the  fistulous  tract,  in  this  way  getting  rid  of  the  undermined  infected 
area.  Such  cases  which  seem  most  difficult  at  first  sight  may  prove  compara- 
tively easy  in  the  end.  If  the  skin  is  much  excoriated  an  effort  should  be  made 
to  heal  it  by  protecting  it  with  a  stiff  bland  salve  and  keeping  it  clean.  G.  W. 
Perkins  in  order  to  get  rid  of  an  infected  skin  area  in  the  way  of  an  abdominal 
incision,  made  a  preliminary  operation  conducting  the  discharges  out  of  the 
way  into  the  right  lumbar  region.     The  bowels  should  be  well  evacuated  and 


INTESTINAL    FISTULA.  G<9 

the  stomach  emptied  before  the  operation.  If  the  fistula  simply  loads  down 
to  an  appendix  which  is  only  slightly  adherent,  the  operation  presents  but  little 
more  difficulty  and  danger  than  the  ordinary  interval  operation.  Halsted  deals 
with  the  fistulous  orifice  by  surrounding  it  with  a  purse-string  suture,  which  is  then 
tied,  closing  the  opening;  the  suture  is  left  long  enough  to  serve  as  a  tractor,  mak- 
ing tense  the  sinus,  and  so  marking  it  out,  while  the  operator  carries  his  dissection 
inward  toward  the  objective  point,  the  intestinal  opening.  Another  plan  is  to  stuff 
into  the  sinus  a  narrow  strip  of  iodoform  gauze  which  serves  to  plug  the  opening, 
the  operator  then  depending  upon  the  rigid  canal  as  his  guide. 

In  a  s  i  m  p  1  e  fistula  the  operator  may  excise  the  adjacent  abdominal  scar 
tissue,  including  the  fistulous  orifice,  and  so  carry  the  dissection  inward  to  the 
bowel;  at  the  same  time  it  is  kept  as  close  to  the  fistulous  tract  as  possible  until 
the  bowel  is  reached.  The  intestinal  end  of  the  fistula  is  then  excised  in  the 
sound  tissues  of  the  bowel,  and  sewed  up  with  fine  silk  mattress  sutures  taking 
in  all  layers  down  to  the  mucosa,  a  continuous  sere-serous  suture  being  applied 
above  these  for  security.  The  parietal  wound  is  then  closed,  down  to  an  opening 
the  size  of  a  little  finger,  which  is  left  with  a  small  drain  f<;r  a  few  days  for 
security. 

Indifficult  cases,  if  the  fistulous  tract  is  a  long  one  walled  in  by  adhe- 
rent intestines  and  cecum,  it  is  not  safe  to  try  the  simple  plan  of  excision,  for 
there  i~  great  risk  of  injuring  the  adjacent  bowel  by  working  in  the  dark  in  this 
manner.  Under  these  circumstances  it  is  best  to  carry  the  skin  incision  completely 
around  the  old  scar,  including  the  fistulous  orifice,  and  to  enter  the  abdominal 
cavity  at  a  distance  above  and  below  the  fistulous  area.  This  gives  a  chance 
to  study  carefully  the  extent  of  the  involvement  of  the  adjacent  intestines, 
which  can  then  be  dissected  free,  together  with  the  omentum;  after  this  the 
fistulous  area  is  gradually  isolated  from  end  to  end  by  working  backward  with  a 
blunt  dissection  needle.  The  bowel  is  then  lifted  out  onto  the  skin  surface,  the 
fistula  is  excised,  and  the  opening  closed  by  suture. 

The  extent  of  a  difficult  operation  for  post-operative  fistula  will  be  real- 
ized by  consulting  the  description  of  W.  W.  Keen  in  the  Medical  News,  De- 
cember 10,  1892. 

An  unusual  instance  of  a  permanent  fecal  fistula  of  the  small  intestine  fol- 
lowing the  opening  of  an  abscess,  which  was  treated  with  great  surgical  skill,  is 
that  of  G.  W.  Perkins,  of  Ogden,  Utah  (Ann.  Surg.,  1896,  vol.  24.  p.  726). 

The  patient,  a  boy  of  sixteen,  had  an  attack  of  "inflammation  of  the  bowels." 
An  incision  through  the  right  semilunar  line  was  followed  by  the  escape  of  several 
ounces  of  offensive  pus  mingled  with  feces;  the  appendix  was  not  seen.  Recovery 
was  rapid,  but  at  the  end  of  a  week  a  small  fistulous  opening,  seen  at  the  operation, 
had  enlarged  to  one-half  an  inch  in  diameter,  and  all  the  feces  passed  through  it. 
The  patient  became  in  a  short  time  much  emaciated  and  debilitated,  and  nine 
months  later  he  appeared  in  the  doctor's  office  anemic,  icteroid,  and  very  feeble, 
walking  with  pain  and  difficulty  and  bending  over  to  the  right.     Near  the  centre  of 


(>M)    CAKE   OF    PATIENT    AFTER   OPERATION     Uli    POST-OPERATIVE   SEQUELS. 

the  cicatrix  of  the  operation  wound  was  an  opening,  easily  admitting  the  index 
finger  into  the  bowel  in  either  direction,  from  which  protruded  a  ring  of  intestinal 
mucous  membrane.  Just  outside  this  opening  was  a  smaller  one  admitting  a  probe 
•I  to  (i  inches  upward  and  backward  to  the  right  lumbar  region,  and  downward  and 
backward  toward  the  true  pelvis.     <  *ver  the  right  pubic  bone  there  was  a  fluctuating 

swelling  which  ruptured  and  discharged  pus.  Charcoal  given  by  the  mouth  ap- 
pealed al  the  fistula  in  ten  minutes.  In  order  to  get  rid  of  the  infection  of  the 
abdominal  wall,  before  opening  it,  Perkins  made  a  free  lumbar  incision,  scraped  the 
wound,  and  inserted  a  large,  long,  rubber  drainage-tube.  In  a  month  the  local 
condition  had  so  much  improved  that  he  was  a  file  to  operate,  w  hen  an  elliptical  piece 
of  the  abdominal  wall  with  the  fistulous  opening  for  its  centre  was  excised,  opening 

the  peril al  cavitj .     After  freeing  this  segment ,  it  was  lifted  out,  bringing  with  it, 

attached  to  its  under  surface,  the  coil  of  small  intestine  in  which  the  fist  tda  lay.  The 
fistula  itself  was  then  excised  and  closed  with  If)  to  20  interrupted  silk  sutures, 
leaving  a  wound  from  2..")  to  I!  inches  long,  and  narrowing  the  lumen  of  the  bowel 
about  one-third.  Altera  slightly  disturbed  convalescence  the  boy  made  a  perfect 
recovery,  and  two  years  later  was  the  picture  of  robust  health. 

Sonnenbi  rg,  in  a  case  of  fistula  of  the  small  intestine  iii  the  neighborhood 
of  fhe  cecum,  attempted  to  relieve  the  difficulty  by  resecting  the  affected  part 
of  the  ileum  and  joining  the  ends  by  means  of  a  Murphy  button.  The  patient, 
however,  unfortunately  died  from  the  progressive  peritonitis  which  had  begun 

at  the  time  of  the  operation.  The  fistula  in  this  case  was  noticed  three  days 
after  the  operation,  when  fecal  matter  was  found  in  the  dressings,  and  three 
days  later  still  the  patient  died. 

When,  owing  to  the  density  of  the  adhesions,  the  extensive  cicatrices,  or 

the  immobility  of  tin'  bowel,  listulas  cannot  he  closed,  several  plans  of  treatment 

come  up  for  consideration.     The  whole  mass  may  be  resected,  as  in  cancer, 

act  in ycosis,  or  ileocecal  tuberculosis,  and  the  sound  end  of  the  ileum  above  the 

disease,  joined  to  the  sound  end  of  the  ascending  colon,  beyond  the  disease.  Incases 
in  which  the  disease  cannot  be  extirpated,  the  ileum  may  be  anastomosed  into 
the  ascending  or  transverse  colon,  and  this  may  be  done  as  a  simple  anastomosis, 
or  the  entire  diseased  ana  may  be  excluded  from  the  continuity  of  the  intestinal 
area  by  amputation  and  closure  by  suture  of  both  ileum  and  colon.  The 
"  ventilated  opening  "  which  v.  Baracz  has  shown  to  he  necessary  for  the  excluded 
bowel  (Archiv  f.  klin.  <'l<ir..  Bd.  58)  may  be  provided  by  the  fistula. 

V.  ElSELSBERG  lArrln'r  f.  Min.  Chir..  1898,  Bd.  ."><>.  p.  22),  under  the  title 
"Ueber  tin'  Behandlung  run  Kothfisteln  und  Stricturen  '/ex  Darmkanales  mittelst 
thr  totalen  Darmausschaltung,"  reports  a  case  where  the  incision  of  a  perityph- 
lic ali~ces<  resulted  in  the  formation  of  an  anus  preternaturalis  cecalis.  A  celi- 
otomy was  done  to  heal  this  condition,  but  on  account  of  the  extensive  adhe- 
sions of  the  cecum,  as  well  as  of  the  coils  of  the  small  intestine  themselves,  neither 
resection  nor  total  exclusion  of  the  bowel  could  be  done;  total  exclusion 
was  impossible,  as  the  operator  could  not  determine  which  was  the  distal  end, 


URINARY    FISTULA.  681 

and  which  the  proximal  portion  of  the  ileum.  Under  these  circumstances  be 
did  a  lateral  ileo-colostomy  (Fig.  350,  p.  689).  By  this  means  the  anus preternatur- 
aUs  was  converted  into  a  fecal  fistula.  Inasmuch  as  this  continued  to  discharge 
freely,  a  second  operation  was  performed  seven  weeks  after  the  first,  when  the 
diseased  portion  of  the  bowel  was  divided  from  the  remaining  sound  tissue,  and 
the  ends  sewed  up  sausage  fashion,  four  lumina,  two  cecal  and  two  iliac,  being 
closed  in  this  way.  This  operation  was  followed  by  a  perfect  recovery.  The 
whole  illness  lasted  about  eight  months.  In  a  favorable  case  an  end-to-end 
anastomosis  of  the  ileum  into  the  ascending  colon  might  be  done. 

Urinary  Fistula. — A  urinary  fistula  is,  fortunately,  of  rare  occurrence 
after  an  operation  for  appendicitis.  A  case  of  this  kind,  which  was,  in  all  prob- 
ability, a  wound  of  the  ureter,  is  reported  by  C.  A.  Powers  (Med.  News,  1899, 
vol.  75,  p.  427). 

A  young  man,  eighteen  years  old,  had  an  acute  attack  of  appendicitis  with  fever, 
and  a  tender  mass  the  size  of  a  thumb  was  discernible  at  the  outer  border  of  the  right 
rectus  muscle.  At  the  operation  an  incision  was  made  in  the  right  semilunar  line. 
The  mass  proved  to  be  an  inflamed  omentum  and  the  small  intestines  were  matted 
together  by  old  adhesions.  The  inflamed  appendix  was  found,  and  dug  out  of  its 
bed  with  much  difficulty,  the  finger  being  used  as  a  hook  to  pull  up  its  tip  from  the 
depths  of  the  pelvis;  as  the  finger  brought  it  into  view,  between  the  loops  of  small 
intestines,  a  gush  of  straw-colored  fluid  appeared  and  continued  to  well  up  through- 
out the  operation,  although  it  was  a  protracted  one.  This  fluid  was  found  to  contain 
urea.  The  appendix,  which  was  4  inches  long,  was  friable,  and  gangrenous  at 
three  points.  The  source  from  which  the  urine  escaped  could  not  be  found ;  when  fluid 
was  injected  into  the  bladder  the  same  amount  was  returned.  An  incision  was 
then  made  just  above  the  symphysis  for  the  purpose  of  examining  the  bladder, 
but  when  this  was  done  no  lesion  could  be  found.  The  wound  was  closed  with  two 
glass  drains  and  an  iodoform  gauze  pack.  Immediately  following  the  operation  there 
was  a  profuse  discharge  of  urine  through  the  wound,  while  about  20  ounces  of  nrine 
were  passed  daily  by  the  urethra.  ( )n  the  fifth  day  the  urinary  fistula  was  com- 
pletely closed,  and  in  six  weeks  was  firmly  healed. 

MtJHSAM  reports  the  case  of  a  vesical  fistula  in  a  man  twenty-eight  years 
old,  who  in  the  course  of  a  third  relapse  in  appendicitis  acquired  a  perfora- 
tion into  the  bladder.  This  was  followed  by  the  discharge  of  large  amounts  of 
pus  in  the  urine  which  also  contained  gas  and  had  a  foul  odor.  The  appendix 
was  released  from  its  adhesions,  and  removed  with  the  utmost  difficulty,  but 
the  point  of  perforation  could  not  lie  found;  cystitis  continued,  but  after  two 
months  the  patient  appeared  to  be  well  again,  until,  later  on,  the  urine  became 
turbid  again,  proved  to  contain  plant  cells  and  undigested  fibres,  and  showed  a 
connection  between  the  cecum,  which  had  been  shelled  out  close  to  the  bladder, 
and  the  bladder  itself.  About  a  year  after  the  first  operation  a  median  incision 
was  made,  when  the  last  loop  of  the  ileum  ascending  to  the  cecum  was  found 


682    CARE   OF   PATIENT    will;   OPERATION    AND   POST-OPERATIVE   SEQUELjE. 

intimately  adherent  to  the  bladder  by  adhesions  which  could  nol  be  separated 
without  great  danger  to  both  bowel  and  bladder.  An  anastomosis  was  then  made 
between  the  ileum  and  the  upper  pari  of  the  cecum,  in  the  hope  of  diverting  the 
fecal  current  from  the  fistula.  The  patient  improved  remarkably,  the  urine 
became  clearer,  and  he  Beemed  to  be  quite  well  except  for  the  fact  that  ihe 
Murphy  button,  used  in  making  the  anastomosis,  failed  to  pass  out.  The 
X-ray  showed  the  button  lying  over  the  right  sacral  iliac  symphysis,  where, 
however,  it  seemed  to  create  im  disturbance. 

Skin  Affections.  —  I  have  found  but  one  instance  in  literature  in  which 
appendicitis  was    followed    by   dermatitis. 

A  girl,  five  years  of  age,  was  seized  with  vomiting  and  violent  abdominal  pain, 
not  localized, and  without  anymeteorism,bu1  accompanied  by  a  general  sensitiveness; 

in  the  lower  abdomen  there  was  an  area  of  dulliess.  After  a  free  stool  the  child  was 
relieved,  hut  a  few  hours  later  she  began  to  complain  again  of  violent  pain.  The 
temperature  rose,  the  pulse  quickened,  and  the  general  condition  grew  worse,  with 
a  recurrence  of  vomiting,  moderate  tympany,  and  some  duhiess  in  the  right  iliac 
fossa,  without  a  tumor, however, nor  any  localized  pain.  At  the  operation  pus  was 
found  in  the  free  abdominal  cavity,  and  a  minute  opening  appeared  in  the  tip  of 
the  appendix,  which  was  somewhat  thickened.  The  appendix  was  removed,  the 
wound  closed  with  several  silk  sutures,  and  drainage  established.  A  fecal  concretion 
as  large  as  a  bean  was  found  in  the  appendix,  surrounded  by  a  gangrenous  area  of 
mucosa  associated  with  the  perforation.  Recovery  was  interrupted  on  the  sixth  day 
by  an  acute  dermatitis  with  fever  as  high  as  III  ('.,  and  a  troublesome,  violent  itching 
followed  by  desquamation.  It  was  not  a  case  of  scarlatina,  as  there  were  no  throat 
Symptoms.  <  >n  the  sixteenth  day  after  operation  there  was  an  elevation  of  tempera- 
ture, and  two  days  later  a  discharge  with  a  fecal  odor.  <  )n  the  twenty-third  day  a 
pointed  object  was  found  in  the  wound,  which  when  drawn  out  proved  to  he  a  female 
ascaris  30  cm.  in  length.  On  giving  santonin  and  calomel,  a  male  and  a  female 
ascaris  were  passed  /«/•  anum.     The  wound  healed  up  to  a  minute  fistula. 

Acute  Yellow  Atrophy  of  the  Liver.— A  case  of  this  condition  occurring  as 
a  sequela  to  removal  of  the  appendix  under  chloroform  anesthesia  is  reported 
by  M.  Ballin  (Ann.  Sun/.,  1903,  vol.  37,  p.  362). 

The  patient,  a  hrassworker,  twenty  years  of  age.  had  three  typical  attacks  of 
appendicitis.  He  was  operated  on  in  the  third,  when  the  appendix,  which  was 
adherent,  friable,  and  covered  with  a  fibrino-purulent  exudate,  was  removed.  The 
stump  was  touched  with  carbolic  acid,  hut  inversion  and  overstitching  were  im- 
possible, as  the  thread  cut  through  the  infiltrated  tissue.  The  abdomen  was  closed 
without  drainage,  the  operation,  which  was  done  under  ether  narcosis,  having  lasted 
hut  twenty-five  minutes.  Two  days  later,  when  the  temperature  and  pulse  were 
normal,  there  was  slight  jaundice  of  skin  and  conjunctiva,  some  vomiting,  and 
restlessness.  Two  days  after  this,  again,  the  jaundice  was  increased,  the  vomiting 
greenish,  and  there  was  delirium.  The  next  day  there  was  noisy  delirium  with  in- 
creased jaundice,  and  vomiting  of  black  fluid,  with  intervals  of  deep  coma.     These 


ileus.  683 

symptoms  all  increased,  the  stools  and  urine  became  involuntary,  and  the  patient 
had  to  he  held  in  bed  by  two  men.  and  finally  tied  there.  The  jaundice  went  on  to 
a  deep  brown  color,  when  venesection  and  intravenous  saline  infusions  were  used. 
The  urine,  six  days  after  operation,  showed  albumen,  casts,  bile,  and  crystals  of 
leucin  and  tyrosin.  From  this  time  on  there  was  a  gradual  improvement,  and, 
ultimately,  complete  recovery. 

Bayard  Holmes  reports  two  similar  cases,  occurring  in  young  women  ("Four 
Clinical  Notes  on  Appendicitis,"  Chicago,  1904,  p.  17),  in  which  the  symptoms 
preceding  death  were,  he  says,  "comparable  only  to  acute  yellow  atrophy." 

Ileus. — An  ileus  is  an  obstruction  of  some  portion  of  the  lower  alimentary 
tract  interfering  with  the  passage  of  the  intestinal  contents.  The  term  ileus, 
now  commonly  used  by  surgeons  to  denote  an  anatomic  condition,  more  properly 
refers  to  the  severe,  twisting,  colicky  pain,  which  is  the  characteristic  sign  of  the 
affection. 

E  t  i  o  1  o  g  v. — The  obstruction  which  produces  an  ileus  may  arise  from 
a  number  of  causes,  such  as  a  volvulus,  or  twisting  of  the 
b  o  w  el,  foil  o  w  i  n  g  a  n  i  a  j  u  r  y ;  a  d.  h  e  s  i  o  n  s  between  loops 
of  bo  w e 1  and  strictures  within  the  16 w e r  a  b  d  o m e n  ; 
the  slipping  of  a  loop  of  bowel  u  n  d  e  r  n  e  a  t  li  a  p  e  r  - 
i  t  o  n  e  a  1  b  and,  resultin  g  f  r  o  m  an  o  1  d  peri  t  o  n  i  t  i  s  ;  t  h  e 
i  n  c  a  r  c  e  rati  o  n  of  a  1  o  o  p  o  f  b  o  w  e  1  under  othe  r  a  d  li  e  r  e  n  t 
loops,  or  under  an  adherent  o  m e  n t  u m  ,  o  r  an  attache  d 
o  r  t  w  i  s  t  e  d  appendix.  Ileus  occurring  as  a  complication  of  appendicitis 
is  oftenest  clue  to  sharp  flexures  caused  by  the  numerous  adhesions  at  the 
terminal  portions  of  the  ileum,  arising  in  the  course  of  nature's  efforts  to  shut 
off  an  infected  area.  When  the  ileus  follows  an  operation  for  appendicitis,  at 
a  date  more  or  less  remote,  it  is  apt  to  arise  from  the  constriction  of  bands  of 
adhesions  cutting  across  the  small  intestine. 

Among  all  the  various  causes  of  ileus,  one  of  the  most  important  is  par- 
alysis of  the  bowel  from  a  gaseous  distention.  This 
distention  may  be  so  marked  and  the  symptoms  of  obstruction  associated  with 
it  so  pronounced  that  the  original  disease  in  the  appendix  is  entirely  masked. 
The  obstruction  in  an  ileus  may  be  immediate  and  complete;  as  a  rule,  how- 
ever, it  comes  on  gradually,  only  becoming  complete  after  a  few  hours,  or,  it 
may  be,  several  days.  Where  the  obstruction  is  only  partial,  the  signs  of  an 
ileus  may  be  intermittent  in  character,  occurring  only  when  the  upper  bowel 
becomes  overloaded.  The  result  of  an  obstruction  is  the  accumulation  of  fluids 
and  gases  in  the  upper  proximal  portion  of  the  bowel,  while  the  lower,  distal 
portion  is  empty  and  contracted.  It  is  of  the  utmost  importance  to  bear  this 
fact  in  mind  when  endeavoring  to  locate  the  obstruction,  in  order  to  avoid 
hunting  aimlessly  among  the  bowels  under  circumstances  when  time  is  too 
precious  a  commodity  to  be  wasted. 


I  is  I     i   \i;i.    OF    PATIENT    \l  I  I :  K   OPERATION    AND    POST-OPERATIVE    SEQUELS. 

E.  v.  Wahl  {Centralbl.  j.  Chir.,  March  2,  1889)  calls  attentioo  to  the  in- 
exactitude of  surgeons  in  failing  to  determine  the  precise  seat  of  an  ileus  before 
operation,  as  will  as  in  the  want  of  satisfactory  clinical  descriptions  of  the  por- 
tion el'  the  bowel  involved.  He  insists  that  an  "anatomical  diagnosis  of  the 
-eat,  nature,  ami  character  of  the  occlusion  must  firsl  he  established  before 
the  knife  is  taken  in  hand."  In  the  firsl  place,  it  is  necessary,  according  to 
him,  to  he  more  exact  in  mapping  out  on  the  abdomen  the  area  of  meteorism, 
ami  not  tn  he  satislieil  with  the  general  vague  statement  that  meteorism  is  pres- 
ent, lie  asserts  emphatically  that  the  obstructed  loop  itself  is  preeminently 
the  seat  of  meteorism,  and  that  this  symptom  is  caused  by  hindrance  In  the 
circulation  and  by  the  decomposition  of  the  contents  of  the  intestine  with  the 
formation  of  gases.  Finally,  he  enunciates  the  dictum  that  "in  certain  forms 
of  occlusion  <>f  the  intestine — strangulation  or  volvulus — a  certain  part  of  the 
intestinal  canal  within  the  abdomen  undergoes  an  abnormal  fixation  and  gase- 
ous distention,  which  under  inspection  is  manifest  by  the  asymmetrical  form 
of  the  abdomen,  and  is  recognized  by  careful  palpation  through  the  distinct 

increase   in   resistance." 

Kader,  following  v.  Wahl  (Centralbl.  f.  chir.,  1891,  No.  26,  p.  106),  states 

that  the  meteorism  is  due  to  an  increased  circumference  of  the  intestine,  oc- 
casioned by  the  follow  in":  factors: 

1.  Increased  thickness  of  the  intestinal  wall-. 

2.  Accumulation  of  fluid  within  the  bowel. 

3.  Development  of  gases  within  the  affected  loops. 

And,  as  the  result  of  experiments  on  dogs,  he  declares  that  meteorism  in  all 
forms  of  intestinal  occlusion  is  a  consequence  of  two  complementary  factors, 
which  are  il)  circulatory  disturbances  in  the  venous  system;  and  (2)  stagna- 
tion and  decomposition  of  the  contents  of  the  bowel. 

In  ileus  following  operation  on  the  vermiform  appendix,  the  obstruction 
is  almost  invariably  situated  in  the  neighborhood  of  the  ileocecal  valve,  that  is 
to  saw  in  the  last  group  of  the  small  intestines  located  in  the  right  lower  abdo- 
men. In  searching  for  an  obstruction,  therefore,  we  are  able  to  neglect  the 
proximal  groups  of  the  ileum  and  jejunum,  and  devote  attention  at  once  to  the 
omentum  and  the  last  group  which  occupies  the  pelvis  and  the  right  iliac  fossa. 
I  would  especially  call  attention  to  the  fact  that  the  terminal  portion  of  the 
bowel  in  this  group  is  usually  found  lying  on  the  pelvic  floor,  from  which  it 
ascends  to  terminate  at  the  ileocecal  valve,  its  mesentery  growing  shorter  and 
shorter  until  at   the  valve  it  almost  disappears. 

A.  T.  Cabot,  in  speaking  of  chronic  obstructions  of  the  bowel  with  recur- 
ring symptoms  of  ileus,  draws  attention  to  the  partial  twists  and 
kinks  found  when  the  terminal  ileum  lies  over  the  head  of  the  cecum,  and 
walls  in  an  inflamed  appendix  to  the  left  and  in  front.  If  the  bowels  are  in 
good  order,  they  are  able  to  pass  their  contents  comfortably  through  such  a 


ileus.  685 

partially  obstructed  coil;  when,  however,  they  are  overloaded,  peristalsis  is 
checked  and  all  the  symptoms  of  an  acute  stoppage  ensue. 

It  is  of  the  utmost  importance  to  recognize  the  fact  that  an  ileus  is  not  due 
simply  to  the  existence  per  se,  of  adhesions  between  the  various  coils  of  intes- 
tines, however  numerous  these  may  he.  The  entire  intestinal  tract  may  he 
bound  together  by  webs  of  adhesions,  or  the  whole  peritoneum  may  actually 
disappear,  without  producing  an  obstruction.  An  obstruction  arises  when  a  loop 
of  bowel  is  caught  and  held  in  a  lower  position  than  that  which  it  naturally 
occupies  in  the  abdomen,  as.  for  example,  when  one  of  the  loops  normally  lying 
well  above  the  pelvis  grows  fast  to  a  pelvic  wound.  If  a  small  area  of  the 
bowel  is  held  fast  in  this  way,  a  sharp  kink  occurs  and  a  knuckle  adhesion,  which 
is  much  like  a  finger  flexed  sharply  upon  itself,  is  formed.  Another  way  in 
which  an  ileus  occurs  is  by  the  formation  of  adhesions  between  two  loops  of 
bowel,  which  then  contract  and  bind  the  intestine  in  one  fixed  position.  Again, 
after  adhesions  have  formed  between  two  different  loops  of  intestine,  another 
loop  may  slip  in  underneath  the  adhesion,  as  under  a  bridge. 

One  of  the  commonest  causes  of  late  post-operative  obstructions  is  the 
gradual  rolling  up  of  a  thin  layer  of  adhesions  into  a  strong  band,  by  the  con- 
tractions and  tuggings  of  the  intestines.  All  band  adhesions  are  formed  in  this 
way.  The  more  recent  the  adhesion  (if  it  is  not  omental),  the  more  apt  is  it  to 
involve  broad  surfaces,  and  on  this  account  the  ditficulties  in  dealing  with  it  are 
increased. 

Symptoms. — The  clinical  signs  of  ileus  are:  vomiting,  at  first  bilious 
and  from  the  upper  intestinal  tract,  then  ill-smelling,  and,  finally,  fecal;  colicky 
pain  coming  on  at  the  same  time  and  usually  beginning  at  one  spot  in  the  right 
lower  abdomen,  after  which  it  becomes  general  and  is  associated  with  vermicular 
contractions  of  the  bowel,  easily  felt,  and  often  visible.  These  symptoms  are 
accompanied  by  gurgling  sounds  due  to  the  movements  of  flatus  in  the  coils  of 
intestine.  A  marked  localized  tympany  soon  develops  and  the  passage  of  flatus 
and  feces  per  anum  ceases  entirely.  The  temperature  is  slightly  if  at  all  affected, 
and  the  pulse  is  at  first  quickened  only  during  the  tormina.  In  the  post-opera- 
tive form  of  ileus  the  development  of  these  symptoms  i<  often  gradual,  and  the 
first  indication  is  an  increasing  difficulty  in  moving  the  bowels. 

The  cardinal  symptoms  of  ileus  are:  Obstipation;  intermittent 
abdominal  pain:  vomiting,  becoming  fecal  in  character; 
gaseous    distention,    often    localized. 

D  i  a  g  n  o  s  i  s  . — A  diagnosis  of  ileus  is  easily  made  in  the  presence  of  the 
symptoms  just  mentioned.  One  of  the  most  characteristic  sums  is  the  formation 
of  a  hard  tumor,  due  to  the  contractions  of  the  intestine  just  above  the  obstruc- 
tion, ainl  easily  detected  by  laying  the  hand  upon  the  abdomen.  The  vermicular 
movements  of  the  bowel  and  the  displacement  of  the  gases  as  they  rumble  from 
looj)  to  loop  are  also  often  easily  felt.  The  leucocyte  count  is  of  little  value, 
because  it  may  show  a  marked  rise  early,  and  then  a  drop. 


<'>M>    CAKE    OF   PATIENT    AFTER   OPERATION    AM)    POST-OPERATIVE   SKql'EL.E. 

Treatment . — The  amount  of  progress  made  in  the  treatment  of  obstruc- 
tion during  the  short  space  of  sixteen  years  is  evident  Oil  the  perusal  of  such  an 

article  as  Roswell  Park's  brief  but  lucid  paper  entitled  " Laparotomy  or  Enter- 
ostomy" i.V.  )'.  Med.  /.'<<■..  March  3,  L888).  It  is  hard  to  realize  that  shortly 
before  this  date  the  treatment  of  ileus  belonged  exclusively  to  the  domain  of 
internal  medicine.  The  emancipation  heralded  by  Pare  and  his  contempo- 
raries began  with  the  introduction  of  surgical  measures  in  the  opening  of  the 
obstructed  bowel  onto  the  skin  surface:  and  then  advanced  to  the  making  of 
larger  incisions,  in  order  to  inspect  the  affected  area.  and.  if  possible,  relieve, 
the  cause  without  doing  an  enterostomy.  KtJMMELL  as  early  as  1887  advocated 
an  exploratory  incision  extending  from  sternum  to  symphysis  (Centrbl.  /.  Chir., 
1887,  No.  1.").  p.  836).  Schede  (Arch.  j.  klin.  chir..  No.  36,  p.  635)  insisted  thai 
"the  fate  of  those  suffering  from  an  ileus  depends  entirely  upon  an  early  diag- 
nosis. There  is,  perhaps,  no  other  acute  disease  in  which  the  patients  ability 
for  resisting  shock  so  rapidly  vanishes." 

A  plan  of  treatment  introduced  by  Madeli  ng  (Arch.  j.  klin.  Chir..  Bd. 
36,  p.  283)  was  to  begin  with  a  small  incision  in  the  abdominal  wall,  through 
which  he  made  such  investigations  as  were  possible  into  the  condition  of 
the  immediate  adjacent  intestine.  He  then  pulled  up  a  loop  of  distended 
gut,  and  held  it  out  of  the  wound  by  two  strong  silk  threads  passed  under  it 
and  through  its  mesentery.  The  patient  was  then  turned  on  his  side,  the  knuckle 
of  intestine  and  the  wound  protected  by  iodoform  gauze,  after  which  the  gut 
was  deliberately  incised,  so  that  all  its  contents  could  escape,  the  outflow 
being  encouraged  by  the  insertion  of  a  soft  catheter.  In  order  to  do  this 
effectually  it  was  necessary  to  wait  for  fifteen  minutes  or  so.  during  which 
time  the  anesthetic  was  sometimes  intermitted.  The  wound  in  the  intestine 
was  then  carefully  closed  by  sutures,  and  after  thoroughly  cleansing  the  parts, 
the  original  abdominal  opening  was  enlarged.  If  an  obstruction  was  found, 
it  was  treated  as  seemed  best,  hut  if  nothing  was  discovered,  the  intestinal  loop 
first  opened,  was  found  again  by  means  of  the  silk  threads  left  in  situ,  and  sewed 
into  the  abdominal  wound,  after  which  it  was  reopened  at  the  point  where  first 
incised,  an  artificial  anus  being  thus  formed  (see  Park,  he.  cit.). 

The  best  treatment  of  ileus,  as  of  other  post -operative  complications, 
is  by  prevention,  effected  by  taking  care  during  the  operation  to  remove,  as 
far  as  possible,  all  existing  difficulties,  and  to  avoid  causing  any  injury  which 
is  liable  to  result  in  obstruction.  This  i<  accomplished  by  a  minimal  exposure 
and  handling  of  the  intestines;  by  keeping  exposed  peritoneal  surfaces  moist 
with  a  warm  saline  solution;  by  hunting  out  and  relieving  all  adhesions  which 
can  possibly  be  found;  by  covering  in  any  raw  or  bleeding  surfaces  with  intact 
peritoneum;  and  by  draining  septic  areas  in  such  a  manner  as  to  prevent  the 
extension  of  the  infection.  If  the  bowel  is  badly  injured  and  requires  extensive 
suturing,  especially  in  operations  which  must,  of  necessity,  be  done  in  haste, 
the  dangers  of  a  fatal  peritonitis,  or  of  an  ileus,  may  sometimes  be  obviated  by 


ileus.  687 

bringing  the  injured  loops  of  intestine  into  the  wound  and  leaving  them  exposed 
there.  Should  this  part  of  the  bowel  break  down  later,  the  discharge  takes 
place  onto  the  surface  and  no  harm  is  done,  as  the  resulting  fistula  may  be  closed 
at  a  later  date.  It  is  best  to  avoid  the  use  of  long  strips  of  gauze  for  the  purpose 
of  draining  between  the  intestines,  as  a  slight  displacement  of  the  coils  of  the 
bowel  serves  to  produce  a  kink  or  an  obstruction. 

When  an  obstruction  occurs  after  a  gauze  pack  has  been  introduced  into 
the  wound,  the  first  thought  of  the  surgeon  should  always  be  that  the  stoppage 
is  due  to  the  pressure  of  the  gauze,  or  to  the  entanglement  of  a  loop  of  the  intes- 
tine by  strips  of  it.  The  first  effort  to  relieve  the  cause  should  be  to  remove 
the  pack,  and  perhaps  readjust  or  straighten  out  any  coil  of  intestine  which  is 
obviously  kinked.  Every  surgeon  of  experience  has  had  occasion,  more  than 
once,  to  relieve  cases  in  this  way,  which  at  first  sight  seemed  alarming.  It  is 
a  good  rule  to  give  an  anesthetic  and  do  this  little  operation  thoroughly,  as  it 
may  obviate  the  necessity  for  a  far  more  serious  operation  later  on.  A  bad  case 
can  also  sometimes  be  relieved  by  opening  the  distended  bowel  in  the  wound 
with  the  cautery  point,  thus  establishing  a  fistula.  Cases  which  have  seemed 
almost  moribund  from  obstruction  and  gaseous  distention  have  been  repeatedly 
saved  by  making  an  artificial  vent  in  this  manner. 

In  cases  in  which  the  bowels  are  becoming  more  and  more  difficult  to  move, 
or  in  those  where  an  obstruction  has  certainly  developed  though  the  vomiting 
and  pain  are  not  yet  pronounced,  if  the  patient's  condition  is  good,  the  surgeon 
may  try  for  a  short  time  to  effect  a  movement  by  giving  enemata,  such  as  a  litre 
of  water  containing  glycerine  and  two  teaspoonfuls  of  turpentine,  or  glycerine 
and  oil;  he  may  also  try  the  administration  of  calomel,  or  even  castor  oil,  by 
the  mouth.  It  is  best  not  to  give  any  nourishment  at  all.  The  passage  of 
gas  is  encouraging,  as  it  is  often  the  premonitory  sign  of  a  fecal  movement, 
but  if  this  does  not  shortly  occur,  especially  if  the  symptoms  continue  unabated 
or  begin  to  grow  worse,  it  is  better  to  interfere  promptly,  rather  than  continue 
to  make  efforts  to  force  a  passage,  which  exhaust  the  patient's  strength.  In 
few  diseased  conditions  is  time  so  important;  a  patient  who  appears  to  have 
been  doing  well  while  purgatives  are  being  poured  into  him  and  the  physician 
is  anxiously  watching  at  his  bedside,  will  often  suddenly  show  signs  of  collapse, 
and  within  an  hour  or  two  it  becomes  evident  that  a  more  radical  plan  of  treat- 
ment has  been  delayed  too  long.  It  is  better  to  make  a  few  mistakes,  and  to 
open  the  abdomen  occasionally  without  necessity,  than  to  delay  systematically 
in  all  cases  and  then,  when  operation  is  performed  as  a  last  resort,  to  lose  even- 
case  operated  upon. 

I  would,  therefore,  advise  operating  promptly, 
as  soon  as  the  patient  fails  to  respond,  provided  the 
classical    signs    of    obstruction    are    present. 

When  there  is  fecal  vomiting  the  stomach  should  be  thoroughly  washed  out 
before  operation.     If  this  cannot  be  accomplished,  it  is  better  to  do  the  opera- 


688    CARE   OP   l'Vlli  \i     UTKi;   OPERATION    AND    POST-OPERATIVE   BEQ1  1.1.  E. 

i  ii hi  under  cocaine  than  to  risk  drowning  the  patienl  in  liis  own  vomil  as  he 
goes  under  the  anesthetic.  Where  time  is  so  important,  all  preparations  should 
have  been  made  beforehand.  The  abdomen  must  be  cleansed  while  the  anes- 
thetic is  being  given,  and  the  operator  stand  ready  to  begin  ll peration  the 

momenl  the  patient  is  ready.  Ii  is  besl  to  give  the  anesthetic  on  the  operating 
table.     The  cardinal  rules  of  operation  in  ileus  are  as  follows: 

1.  The  operation  must  be  dune  as  promptly  as  possible,  when  the  diagnosis 
is  once  clearly  made. 

2.  It  must  be  as  brief  as  it  can  be  consistently  with  thorough  work. 

3.  As  little  anesthetic  as  possible  should  be  given,  but  the  relaxation  must, 
nevertheless,  be  complete.  Local  anesthesia  (Schleich's  solution)  is  best  in 
bad  cases  where  there  has  been  much  fecal  vomiting  (see  Chap.  XXIII). 

•1.  The  bowels  should  be  handled  as  little  as  possible. 

5.  It  is  especially  important  to  avoid  pulling  upon  the  bowels. 

6.  Evisceration  should  be  avoided  as  far  as  possible,  the  proximal  distended 
coils  in  the  abdominal  cavity  being  left  in  situ,  and  the  search  directed  beyond 
them  (distally),  near  the  ileocecal  valve,  for  the  obstruction. 

7.  It  is  better  to  empty  any  escaping  over-distended  bowels  than  to  attempt 
to  force  them  back  with  great  difficulty. 

8.  If  the  obstruction  is  not  entirely  overcome,  as  shown  by  the  distended 
bowel  beginning  to  unload  itself  at  once  into  the  lower  intestine,  a  distended  loop 
must  be  brought  up  into  the  wound  and  left  there,  to  be  opened  a  little  later. 

9.  If  there  is  any  doubt  as  to  the  complete  relief  of  the  obstruction,  a  loop 
of  bowel  must  be  brought  up  into  the  wound,  in  readiness  for  enterostomy. 

10.  The  use  of  saline  infusions  with  a  little  adrenalin  (15  to  20  cc.  of 
1  :  1000  solution  of  adrenalin  in  800  to  1000  cc.  of  normal  salt  solution)  is  of 
value  in  keeping  up  the  heart  action. 

11.  livery  possible  effort  must  be  made  to  keep  up  the  body-temperature  and 
to  avoid  chilling  the  patient  from  exposure  of  the  viscera. 

The  operator  who  opens  the  abdomen  to  relieve  an  ileus  must  in  each  case 
do  one  of  three  things:  he  can  (a)  overcome  the  obstruction  by  dividing  adhe- 
sions or  loosening  attached  coils  of  intestine;  if  unable  to  overcome  the  obstruc- 
tion, he  can  (b)  short-circuit  the  bowel  across  the  obstructed  area  by  an  anasto- 
mosis of  the  ileum  into  the  colon;  or  he  can  (c)  bring  a  loop  of  the  bowel  above 
the  obstruction  onto  the  surface  for  an  enterostomy  later  on.  If  the  last  method 
i-  used,  it  is  well  to  mark  the  point  for  incision  by  inserting  black  silk  threads  in 
the  outer  coats  of  the  bowel  and  leaving  them  hanging  out  of  the  wound.  When 
the  operator  is  uncertain  as  to  whether  he  has  completely  overcome  the 
obstruction,  he  can  employ  a  combination  of  these  methods  by  leaving  the 
wound  open  and  bringing  a  loop  of  bowel  into  it,  ready  to  be  incised  if  the 
symptoms  persist. 

Where  the  original  operation  has  been  a  comparatively  simple  one,  the  oper- 
ator may  expect  to  find  nothing  more  than  the  simple  adhesion  of  a  knuckle 


ILEUS. 


689 


of  intestine,  or  of  the  free  border  of  the  omentum,  under  which  the  ileum 
has  slipped,  to  the  head  of  the  cecum,  the  latter  forming  a  large  gurgling 
tumor  yielding  signs  of  an  incomplete  obstruction.  I  saw  such  a  case  in 
consultation  with  B.  C.  Hirst,  in  which  the  patient  suffered  severe  paroxysms  of 


Fig.  350. — Hirst's  Case.     Intestinal  Obstruction  Following  Operation  for  Appendicitis  Due  to  Omen- 
tal Adhesion  over  Stump  of   iiie  Appendix.     January  IS,   1903. 


pain  at  variable  and  sometimes  considerable  intervals,  associated  with  swelling 
to  the  right  of  the  umbilicus  and  an  extremely  tender  abdomen.  The  obstruc- 
tion, however,  was  manifestly  partial,  as  there  was  no  fecal  vomiting,  and  the 
passage  of  the  intestinal  contents  was  obviously  only  impeded.  At  the  operation 
the  edge  of  the  omentum  was  found  adherent  in  such  a  manner  as  to  form  a  strong 
44 


690    I   w:l     "l     I'M  HAT   AFTEB   OPERATION    AND   POST-OPERATIVE   SEQUEL*. 

band  attached  at  tin-  seat  of  the  appendix  operation.  A  large,  deeply  reddened 
loop  of  ileum  had  slipped  under  this  band  and  then  dropped  down  in  front  of 
the  omentum  so  as  to  form  an  inc  anplete  strangulation.  Fig.  350  shows  the 
condition  as  found  at  the  operation.  In  such  a  case  the  old  incision  maybe 
cautiously  reopened,  after  which  the  bowel  is  released  by  freeing  and  suturing 
the  loop,  or  by  dividing  the  omentum.  In  the  case  of  a  relative  of  mine,  a  boy 
of  fourteen,  1  made  a  little  opening  parallel  to  and  to  the  inside  of  the 
first  incision,  after  which  I  freed  a  single  knuckle  of  the  ileum  and  evacuated 
a  serous  accumulation.      Recovery  followed. 

If  a  loop  of  bowel  is  evidently  gangrenous  ami  in  need  of  resection,  while  at 
the  same  time  the  patient's  condition  will  not  permit  any  extension  of  the 
operation,  the  difficulty  may  he  met.  and  life,  in  many  instances  saved,  by  the 
simple  expedient  of  bringing  out  the  gangrenous  loop  onto  the  surface  of  the 
body,  together  with  a  sufficient  amount  of  the  adjacent,  apparently  healthy 
bowel  to  provide  for  a  possible  extension  of  the  gangrene.  The  diseased  bowel 
is  opened  and  left,  carefully  wrapped  in  dressings,  isolated  from  the  wound.  At 
a  later  date,  when  the  sloughing  process  is  completed,  the  ends  of  the  bowel 
may  be  anastomosed  without  using  a  general  anesthetic. 

W'hei.  there  has  been  an  abscess,  or  when  the  adhesions  have  been  extensive 
at  the  original  operation,  it  i^  best  to  open  the  abdomen  by  a  long  incision 
medianwards  from  the  original  one.  and  not  more  than  one  or  two  inches  distant 
from  it.  The  viscera  must  first  be  carefully  inspected,  in  order  to  determine 
whether  the  obstruction  i-  situated  at  a  particular  point  or  is  caused  by 
general  adhesions.  The  distended  portion  of  the  intestine  must  next  be 
noted,  as  well  as  the  presence  of  any  collapsed  bowel  on  the  proximal  side  of 
the  ileocecal  valve,  which,  if  present,  must  be  traced  up  to  the  limit  between 
the  two,  after  which  the  operator  may  proceed  to  deal  with  the  disease  accord- 
ing to  the  finding-,  which  are  likely  to  be  one  of  the  following  conditions: 

1.  A  band,  or  bands  of  lymph  stretching  over  the  pelvis  and  the  intestine-. 

2.  A  twist  in  the  bowel,  or,  in  other  words,  a  volvulus. 

:!.   Omental  adhesions  with  a  loop  of  bowel  caught  under  the  free  edge. 

4.  A  loop  of  bowel,  or  several  loops,  adherent  at  the  site  of  the  operation, 
at  the  abdominal  incision,  to  an  abscess  wall,  or.  it  may  be.  in  the  pelvic  cavity. 

5.  Angulation  of  the  ileum,  produced  by  the  adhesions  binding  together 
distant   loops. 

6.  Angulation  of  the  ileum  over  the  cecum. 

7.  General  adhesions  among  the  bowels  in  which  a  particular  line  of  demar- 
cation, defining  the  obstructed  area,  is  scarcely  discoverable. 

Great  care  must  be  taken  not  to  overlook  bands  of  adhesions,  especially  if 
they  are  a  little  distance  from  the  field  of  operation,  when  it  is  very  easy  to  do 
so.  I  had  a  case  of  this  kind  recently,  in  which  an  obstruction  followed  an 
operation  for  appendicitis,  and  the  bowels  were  so  matted  together  that  a  feed 
fistula  had  been  formed  to  give  relief.     I  opened  the  abdomen  widely  in  the 


ILEUS.  691 

old  scar,  dissected  out  and  sewed  up  two  fistulas,  one  in  the  cecum  and  one 
under  the  ileum,  and  then  found  the  obstruction  lying  at  the  splenic  flexure  of 
the  colon.  The  proximal  portion  of  the  large  bowel  was  so  enormously  dis- 
tended that  it  resembled  a  large  stomach,  and  appeared  to  fill  the  abdomen. 

After  dividing  numerous  adhesions  around  the  head  of  the  cecum,  and  under  a 
long  scai'  in  the  median  line,  I  found  some  strong  bands  of  adhesions  pacing 
from  the  pelvis  upward  in  the  direction  of  the  obstruction.  These  I  caught 
under  my  fingers,  and  divided  them  with  scissors,  being  guided  in  doing  so  by 
touch  alone,  on  account  of  the  distance  from  the  wound.  The  tumors  which 
had  been  formed  by  the  colic  mass  disappeared  when  the  patient  recovered. 
Later  a  tumor  was  found  at  the  splenic  flexure,  necessitating  an  anastomosis  of 
the  ileum  into  the  descending  colon. 

When  a  mass  of  adhesions  is  to  be  dealt  with,  it  is  best  to  handle  it  as  a  whole, 
first  locating  the  sound  areas  above  and  below,  and  then,  if  possible,  bringing 
the  mass  outside  and  surrounding  it  on  all  sides  witli  wet  saline  gauze.  The 
loops,  which  stretch  like  bridges  across  other  loops,  are  best  detached  by  pull- 
ing them  apart  with  pledgets  of  wet  gauze,  a  light  being  held  at  the  same  time 
on  their  other  side.  In  this  way,  as  the  adhesions  are  pulled  apart  a  little 
at  a  time,  it  is  possible  to  cut  between  the  loops  without  injuring  the  coats 
of  the  bowel  or  of  the  blood-vessels.  This  method  of  inspecting  adhesions 
so  as  to  differentiate  between  them  and  the  viscera,  and  at  the  same  time  dis- 
cover the  presence  of  blood-vessels,  I  have  called  diaphanoscopy,  in 
order  to  emphasize  it  as  a  practical  procedure.  It  is  well  not  to  refine  too 
much  in  dividing  all  the  adhesions  between  areas  of  the  bowel  which  are  natu- 
rally separated  by  only  a  few  centimetres. 

The  worst  cases  of  adhesions  are  those  on  the  pelvic  floor.  The  treatment 
of  these  requires  abundant  room  and  light,  and  can  only  be  accomplished  after 
displacing  the  other  bowels.  After  isolating  the  affected  loops  of  bowel  in  the 
manner  just  described,  it  is  best,  if  circumstances  will  permit,  to  elevate  the 
pelvis,  and  then,  while  making  a  little  gentle  traction  upon  the  bowel,  to  snip 
the  adhesions  very  slowly  and  deliberately  with  scissors.  If  the  coats  of  the 
bowels  are  injured,  one  or  two  fine  mattress  sutures  must  be  put  in  at  once. 
In  a  case  where  the  general  adhesions  are  badly  matted,  it  is  best  to  be  satisfied 
with  bringing  out  a  distended  loop  of  the  intestine  to  be  incised  soon  after  the 
operation;  a  few  weeks  later  the  fistula  may  be  closed. 

When  the  adhesions  are  too  extensive  to  be  dealt  with,  or  when  there  is 
imminent  risk  of  rupturing  the  intestines  in  separating  them,  a  lateral  anasto- 
mosis of  the  distended  ileum  into  the  cecum  may  be  made,  as  in  the  following 
case  treated  by  J.  M.  T.  Finney: 

In  1S96  the  patient,  then  a  boy  of  fourteen,  developed  an  appendicitis  for  which 
W.  S.  Haisted  operated,  removing  a  gangrenous  appendix  9  inches  long.  There  was 
a  large  abscess  with  a  proteus  infection  in  Douglas'  cul-de-sac,  and  a  general  plastic 


692    CARE   OF   PATIENT   AFTER  OPERATION   AND   POST-OPERATIVE   SEQUELS. 

peritonitis  had  spread  over  the  bowels.  An  area  of  gangrene  in  the  cecum  about  3 
cm.  in  diameter  was  packed  and  left :  following  this  treatment  he  had  a  fecal  fistula 
lasting  six  months,  which  finally  closed  spontaneously.     He  made  a  good  recovery, 

and  in  a  few  years  he  developed  from  a  small  boy  to  a  large  man  over  six  feet  tall 
and  weighing  17o  pounds.  Six  years  after  the  operation  he  had  a  sudden  acute 
attack  of  intestinal  pain  with  immediate  fecal  vomiting.  In  forty-eight  hours  there 
was  a  complete  obstruction,  no  more  feces  nor  gas  being  passed;  there  was.  however, 
very  little  distention.  He  seemed  utterly  collapsed,  with  a  pulse  of  16U  and  a  tem- 
perature of  101°  F.  Operation  was  performed  forty-eight  hours  after  theonsel  of  the 
at  lack,  and  adhesions  were  then  found  so  extensive  that  two  anil  a  half  hours  were 
spent  in  freeing  them,  during  which  the  bowel  was  torn  and  sutured  in  four  places. 
As  he  seemed  to  tie  in  collapse,  a  loop  of  intestine  near  the  cecum  was  brought  out  of 
the  wound  and  the  operation  concluded.  ( In  opening  this  loop  it  proved  to  be  distal 
to  the  obstruction,  and  no  relief  was  obtained.  Twenty-four  hours  later  the  ab- 
domen was  reopened,  and  on  incising  an  enormously  distended,  black  loop  of  bowel 
a  large  amount  of  gas  and  fecal  accumulations  were  evacuated.  The  patient  was 
much  shocked,  but  a  rapid  improvement  followed;  six  weeks  later  the  abdomen  was 
again  opened  and  the  fistula  thus  formed  closed,  but  it  proved  utterly  impossible 
to  reach  the  obstruction,  which  lay  like  a  large  mass  in  the  pelvis.  A  lateral  anas- 
tomosis of  the  ileum  into  the  cecum  was  then  made,  which  was  followed  by  an  im- 
mediate improvement  and  an  undisturbed  convalescence.  The  patient  is  now  able 
to  go  about  without  pain,  vomiting,  or  fever,  and  his  evacuations  take  place  normally. 

Coley  reports  a  ease  (Ann.  Surg.,  100(1,  vol.  22,  p.  451)  of  a  boy  operated 
upon  in  April.  1896,  for  an  acute  appendicitis  from  which  lie  made  an  uneventful 
recovery.  In  August  of  the  same  year  he  developed  symptoms  of  acute  intes- 
tinal obstruction,  and  on  opening  the  abdomen  three  and  a  half  feet  of  intestine 
were  found  strangulated,  which  it  was  necessary  to  resect.  The  procedure 
was  followed  by  a  fistula,  the  boy's  general  health  failed,  and  he  became  greatly 
emaciated.  At  a  second  operation,  in  November,  1899,  an  incision  2  inches  long 
was  made  to  the  left  of  the  sinus,  the  adhesions  were  separated,  and  the  ends  of 
the  gut  resected,  after  which  they  were  approximated  with  a  Murphy  button. 
The  wound  was  drained  for  a  week.  The  boy's  health  improved  rapidly  and 
he  gained  23  pounds  in  six  weeks. 

Hernia. — Hernia  following  an  operation  for  appendicitis  is  due  to  a  separa- 
tion of  the  firm  aponeurotic  and  muscular  structures  which  constitute  the 
natural  support  of  the  abdominal  viscera.  Such  a  diastasis  is  followed  by  an 
eversion  of  the  thinned  out  cicatricial  tissue  so  as  to  form  an  extra-peritoneal 
diverticulum  or  pouch  which  is  occupied  by  the  omentum  or  the  intestines.  A 
hernia  of  this  kind  may  occur  at  one  or  several  places  in  the  tract  of  the 
wound,  and  generally  makes  its  appearance  after  an  interval  of  a  few  months 
to  one  or  two  years  after  the  operation. 

E  t  i  o  1  o  g  y. — As  regards  the  frequency  of  hernia  following  operations  upon 
the  appendix:  Homer  Gage  found  19  hernias  in  228  eases  operated  upon  for 
appendicitis,   the  subsequent  history  of  which  he  investigated.     This  is  less  than 


HERNIA.  693 

19  per  cent.,  and  all  made  their  appearance  in  cases  which  had  been  drained; 
17  appeared  in  the  first,  and  2  in  the  second  year  after  operation.     The  greater 

number  occurred  during  the  first  six  months. 

Post-operative  hernias  are  more  apt  to  occur  where  the  tissues  have  lost 
their  tone,  or  in  flabby  neurasthenic  patients.  There  is,  of  course,  a  greater 
liability  to  hernia  when  a  long  abdominal  incision  has  been  made,  but  the  pre- 
vailing impression  that  a  tiny  incision,  from  an  inch  and  a  half  to  two  inches  in 
length,  is  a  guarantee  against  the  occurrence  of  hernia  is  not  borne  out  by  the 
facts.  I  have  myself  seen  a  case  in  which  a  minute  incision  about  5  cm.  long  at 
the  outer  border  of  the  rectus  muscle  suppurated,  and  a  year  later,  when  I  ope- 
rated upon  the  patient,  a  well-built  muscular  young  man,  there  was  an  omental 
hernia  at  this  point.  One  of  the  most  serious  objections  to  Ions  incisions, 
especially  when  made  parallel  to  the  border  of  the  rectus  muscle,  is  the  fact  that 
it  is  still  the  common  practice  to  divide  the  ti-sues  without  any  effort  to  save  the 
nerve  trunks  which  supply  the  rectus.  When  these  nerves  are  thus  ruthlessly 
cut,  an  atrophy  of  the  muscle  follows,  and  even  if  a  hernia  does  aot  take  place,  there 
may  be  a  distinct  weakness  and  bulging  of  the  abdominal  wall  over  the  atrophied 
area.  A  careless  closure  of  the  abdominal  wall,  associated  with  neglect  in  bring- 
ing the  layers  together  in  their  proper  order,  or  carelessness  in  placing  the  sutures 
at  too  great  intervals,  also  predisposes  to  hernia,  which  is  more  apt  to  occur 
in  patients  who  are  slender  at  the  time  of  the  operation,  but  grow  stout  soon 
afterward  and  lead  a  life  of  active  exertion.  The  commonest  of  all  causes,  how- 
ever, is  the  necessity  for  leaving  the  wound  open  for  drainage  in  absce--  cases.  A 
wound  of  this  description  closes  slowly,  and  when  it  finally  does  so,  the  cicatrized 
margins  are  held  together  by  a  veil  of  scar  tissue  that  yields  readily  to  any  pres- 
sure from  within,  such  as  is  brought  to  bear  upon  it  whenever  the  abdominal 
walls  contract  upon  the  contained  viscera.  If  through  some  fault  in  technic,  or 
some  accidental  contamination,  a  healthy  wound  is  infected  after  closure, 
breaks  down,  and  finally  closes  only  after  suppuration,  the  final  result  is  the 
same  as  in  cases  which  have  been  drained,  and  a  hernia  is  likely  to  result. 

Prophylaxis,  which  is  the  best  safeguard  against  hernia,  lies  in  the  use  of  a 
small  incision  whenever  it  can  be  employed  with  equal  safety,  and  in  the  separa- 
tion of  the  muscular  layers  without  cutting  them  (McBurney,  see  Chap.  XXIII, 
p.  533).  I  cannot  too  earnestly  advise  against  the  unnecessary  division  of  the 
important  nerve  trunks,  the  analogues  of  the  intercostal  nerve  trunks  above, 
which  supply  the  abdominal  muscles.  It  is  one  of  the  chief  advantages  of 
interval  operations  that  it  is  never  necessary  to  use  drainage  after  them,  and 
that  the  diseased  appendix  can  be  removed  through  so  small  an  opening  that 
liability  to  the  formation  of  a  hernia  is  minimized.  In  drainage  cases  some- 
thing  may  be  done  to  reduce  the  liability  to  hernia  by  establishing  such  free 
drainage  for  the  first  few  days  that  the  a  1 '-IT—  quickly  empties  itself  and  begins  to 
contract.  The  external  wound  may  then  be  rapidly  closed,  and  to  this  end 
provisional  interrupted  sutures  of  silver  wire  are  laid  during  the  operation  as 


694     CARE   OF    PATIENT    AFTER   OPERATION    AM)    POST-OPERATIVE    SEQUELS!. 

though  the  layers  of  wound  were  to  be  closed  entirely  and  at  once :  they  are  then 
drawn  aside  and  left  loose  until  the  drainage  is  almost  completed,  when  the  wound 
may  he  rapidly  closed  down  to  a  small  orifice  which  at  last  fills  in  with  a  plug  of 
cicatricial  tissue.  When  the  abscess  extends  down  into  the  pelvis, drainage  by  the 
vagina  or  by  the  rectum  is  preferable,  both  on  account  of  its  greater  efficiency 
in  a  dependent  position  and  the  fact  that  any  risk  of  hernia  is  obviated.  Drain- 
age cases  should  he  kept  in  bed  until  the  wound  is  firmly  closed;  the  physician 
will  then  at  least  save  himself  the  blame  which  is  sure  to  he  laid  upon  him  if  he 
hurries  the  patient  out  of  bed,  and  a  hernia  subsequently  forms.  Whenever 
there  is  any  reason  to  fear  the  formation  of  a  hernia,  the  patient  should  wear  a 
snug-fitting  bandage. 

In  spite  of  the  utmost  precautions  a  certain  percentage  of  hernias  are  inevit- 
able as  long  as  surgeons  are  forced  to  operate  in  the  suppurating  stages  of  appen- 
dicitis. It  must  he  remembered  that  in  all  such  cases  the  operation  is  essen- 
tially a  life-saving  operation  procedure,  and  the  risk  of  a  hernia  must  hi'  accepted 
as  a  trivial  consideration  in  comparison  with  the  danger  from  which  the  patient 
is  rescued.  It  is  best  to  forewarn  him  in  such  a  case,  either  just  before  or  soon 
after  the  operation,  and  advise  him  to  accept  cheerfully  an  inconvenience  which 
is  so  easily  remedied  by  subsequent  operation. 

Treatment. — The  proper  treatment  of  a  hernia  is  the  excision  of  the 
scar  together  with  the  hernial  sac,  followed  by  the  careful  approximation  of  sound 
tissues  in  their  natural  order  and  relations,  from  the  peritoneum  to  the  skin 
surface. 

It  is  important  to  remember  that  while  the  hernial  orifice  feels  like  a  sharply 
defined  ring  as  large  as  the  end  of  the  linger,  that  is  to  say.  an  inch  or  more  in 
diameter,  this  ring  is  surrounded  by  thinned  out  areas  of  scar  tissue,  which 
often  involve  the  entire  length  of  the  original  wound,  and  are  sometimes  cribri- 
form. In  order  to  effect  a  radical  cure  of  the  rupture,  this  whole  area  must  he 
dissected  out.  A  ventral  hernia  can  never  he  cured  by  simply  exposing  ami 
suturing  the  sharp  margins  of  the  neck  of  the  sac.  Let  me  reiterate  and  empha- 
size the  fact  that  the  operation  for  hernia  must  not  only  include  the  actual, 
manifest,  hernial  sac  with  it<  orifice,  hut  the  entire  weakened  area  in  which  the 
hernia  is  situated,  and  in  which  it  is  progressively  extending  its  boundaries  from 
month    to    month. 

The  operator  proceeds  by  excising  the  scar  and  baring  the  tendinous  mus- 
cular tissues,  which  are  healthy  and  well  vascularized;  the  various  anatomic 
-tinctures  must  then  he  sought  out  and  recognized  individually,  after  which 
they  are  laid  hare  so  that  they  can  he  brought  broadly  together.  As  a  suture 
material  it  is  best  to  use  fine  silk  or  silver  wire,  at  intervals  of  from  2  to  2..")  cm., 
-o  a-  to  splint  the  tissues  together  in  their  proper  order;  catgut  may  be  employed 
between  these  sutures  to  secure  accurate  approximation.  After  such  an  opera- 
tion the  patient  should  remain  in  bed  not  less  than  three  weeks,  and  go  about 
with  caution  for  many  weeks  longer. 


HERNIA. 


695 


When  the  hernia  is  at  the  border  of  the  right  rectus  muscle,  its  cure  is  more 
difficult,  as  the  lateral  oblique  muscles  must  be  united  to  the  vertical  rectus 
instead  of  being  approximated  to  homonymous  tissues,  as  in  hernias  situated 
more  laterally.     A.  B.  Johnson  gives  a  clear  description  of  the  procedure  to  be 


Fig.  351. — Showing  Large  Hernia  Following  Incision  in  the  Semilunar  Line  for  Appendicitis;    First 

Operation  Elsewhere,  Operation  for  Hernia  and  Floating  Kidney  in  Gynecological  Clinic. 

J.  H.  H.     J.  R.,  set.  thirty.     January  L'4,  1903.     Recovery. 

pursued  for  hernia  in  the  semilunar  line  {Ann.  Surg'.,  1899,  vol.  29,  p.  625). 
The  patient,  a  woman,  forty  years  of  age,  had  been  operated  upon  at  the  Roose- 
velt Hospital  for  an  appendicitis  with  abscess,  and  three  years  later  she  was 
re-admitted  with  a  hernial    protrusion    measuring   •'■>   by   4    inches,    situated 

at  the  right  border  of  the  rectus  muscle.     After  excision  of  the  scar  and  of  the 


696    I   w.'l     OF    PATIENT    AFTER   OPERATION    AND   POST-OPERATIVE   SEQ1  ELM. 

peritoneal  sac.  the  outer  margin  of  the  hernial  ring,  consisting  of  the  apo- 
neurosis of  the  external  oblique  and  tendinous  portion  of  the  internal  oblique 
and  the  transversalis,  was  split;  the  external  oblique  was  then  dissected  away 
from  its  underlying  structures    for  a   distance   of   2   inches   over  a    vertical 


■  i  t  o  n . 


\  ■  m 

^-^  M  J'  \± 

— B 

— «    -^-^- 

\- 

11 

^ec! 

^- — 

W 

1 

/ 

\          ^WN 

i.  • 

\ 

Flo.  '3o~. — Showing  Operation  fob  Hlkma  Dovetailing  Rectus  between  the  Broah  Abdominal  Mi  b<  leb. 


area  4  inches  in  length.  Ijxm  the  inner  side  of  the  hernial  opening  the  sheath 
of  the  rectus  was  laid  open  for  a  distance  of  4h  inches.  The  internal  oblique 
and  the  transversalis  were  then  attached  to  the  posterior  layer  of  the  rectus 
sheath  by  catgut   sutures,  while  the  body  of  the  rectus  muscle  was  dragged 


HERNIA. 


ml 


from  its  sheath  and  attached  by  mattress  sutures  to  the  under  surface  of  the 
aponeurosis  of  the  external  oblique,  so  as  to  cover  completely  the  site  of  the 
hernial  protrusion.  The  free  margin  of  the  aponeurosis  of  the  external  oblique 
was  then  sutured  onto  the  anterior  surface  of  the  rectus  sheath,  and,  lastly, 
the  skin  wound  was  closed.  Five  months  later  there  was  no  evidence  of  weak- 
ness in  the  region  of  the  scar.  The  method  of  closure  was  not  unlike  that  used 
in  one  of  our  own  cases,  which  is  here  figured. 

Fig.  351  shows  the  characteristic  appearance  of  a  large  hernia  in  the  right 
semilunar  line;   the  drawing  represents  the  flaccid  scar  tilled  in  with  thin  skin. 


Continuous   suture   of     Peritoneum 


Fig.  353. — Showing  in  Detail  Method  of  Drawing  Rectus  between  Muscles. 


The  larger  opening  in  the  diastasis  is  characteristically  in  the  lower  part  of  the 
wound.  The  incision,  which  had  been  made  in  another  clinic,  had  evidently  been 
closed  by  through-and-through  sutures  with  drainage  below.  The  method  of 
closure  is  shown  in  Figs.  352  and  353.  After  dissecting  out  the  scar  tissue, 
the  margin  of  the  rectus  muscle  is  exposed,  clean  and  clear,  throughout  the 
entire  length  of  the  wound.  The  lateral  muscles  are  likewise  laid  bare.  The 
next  step  is  to  split  the  lateral  muscles,  separating  the  external  oblique  with  its 
stronger  fascia  from  the  internal  oblique  ami  the  transversalis  below.  The 
sutures  are  shown  in  full  view  in  Fig.  352,  while  Fig.  353  exhibits  the  method  of 
passing  a  single  suture  in  profile. 


CHAPTER   XXIX. 

RELATION  BETWEEN  APPENDICITIS  AND  GYNECOLOGICAL 

AFFECTIONS. 

GENERAL  CONSIDERATIONS. 

Pozzi,  in  1800,  and  also  Teiullox,  in  1890,  emphasized  the  importance  of 
the  relationship  between  appendicitis  and  diseases  of  the  pelvic  organs  in  women, 
but  it  is  only  within  the  past  live  or  six  years  that  a  general  appreciation  of 
this  relationship  has  been  manifested.  Previous  to  this  time,  and  even  to  a 
great  extent  to-day,  the  relative  immunity  of  women  to  inflammation  of  the 
appendix  has  been  chiefly  dwelt  upon,  the  exemption  being  partly  attributed 
to  the  supposed  accessory  blood-supply  from  the  ovarian  vessels.  Some  writers, 
on  the  other  hand,  recognizing  the  coincident  infection  of  the  appendix  and 
pelvic  organs,  believe  that  the  infection  has  been  conveyed  from  the  one  to  the 
other  through  a  pre-existing  lymphatic  connection  between  the  appendix  and 
the  right  ovary.  It  is  now,  however,  generally  conceded  that  the  vascularization 
of  the  appendix  is  similar  in  the  two  sexes,  and  that  an  additional  blood-supply 
from  the  ovarian  or  spermatic  vessels,  while  occasionally  observed,  is  very  incon- 
stant. It  is  also  well  recognized  that  diseases  of  the  pelvic  organs  in  women  are 
often  the  chief  factor  in  exciting  an  appendieal  attack,  and.  what  is  of  still  greater 
significance,  thai  appendicitis  is  often  the  direct  cause  of  tubal  and  ovarian 
disease,  tlie  secondary  infection  in  either  case  being  due  to  contiguity  and  not 
to  continuity  of  structure.  The  confusion  of  diagnosis  which  frequently  occurs 
between  the  two  is  of  great  importance,  for  patients  suffering  from  chronic  appen- 
dicitis are  sometimes  subjected  to  prolonged  treatment  for  supposed  pelvic 
disease,  while,  on  the  other  hand,  a  case  of  acute  salpingitis  may  lie  operated 
on  for  appendicitis.  I  would  especially  emphasize  the  fact,  mentioned  else- 
where (see  Chap.  XVI),  that  dysmenorrhea  is  in  many  cases 
wholly  due  to  the  presence  of  a  chronically  inflamed 
appendix.  It  is  partly  due  to  mistaken  diagnoses  as  well  as  to  the  failure 
to  recognize  the  appendieal  origin  of  some  cases  of  salpingo-ovaritis  that  appen- 
dicitis is  found  to  be  so  much  less  frequent  in  women  than  in  men.  In  Chap. 
XVI  it  is  noted  that  of  the  cases  of  uncomplicated  acute  appendicitis  admitted  to 
the  surgical  department  of  the  Johns  Hopkins  Hospital,  about  40  per  cent, 
were  women  and  60  per  cent,  men;  but  if  we  add  the  cases  admitted  to  the 
gynecological  clinic,  usually  with  a  diagnosis  of  pelvic  disease,  practically 
the  same  proportion  obtains  for  the    two   sexes;  while   the    cases   of  chronic 

69S 


APPENDICITIS   AND   GYNECOLOGICAL   AFFECTIONS.  69S 

appendicitis  are  in  the  ratio  of  4  in  females  to  5  in  males.  I  have  not  in- 
cluded in  these  statistics  the  cases  of  acute  and  chronic  appendicitis  which 
were  associated  with  gynecological  affections,  but  if  these  cases  are  added, 
out  of  a  total  of  over  900  cases  of  appendical  disease  admitted  to  the  Hospital, 
the  number  occurring  in  women  is  slightly  greater  than  in  men.  It  would  appear, 
however,  that  the  most  severe  forms,  especially  cases  complicated  with  general 
peritonitis,  are  more  common  in  the  latter,  occurring  in  the  Johns  Hopkins  Hos- 
pital in  the  ratio  of  2  to  5. 

The  relationship  between  disease  of  the  vermiform  appendix  and  disease 
of  the  pelvic  organs  in  women  may  be  either  accidental  or  causal;  and  the 
most  obvious  classification  of  disease  of  the  appendix  from  this  point  of  view  is 
the  following: 

1.  Cases  in  which  the  disease  of  the  appendix  is  primary,  and  the 
pelvic  affection  is  second  ary ,  that  is  to  say,  consequent  on  the  lesion  of 
the  appendix. 

2.  Cases  in  which  the  gynecological  affection,  whether  it  is  tubal,  uterine, 
or  ovarian,  is   primary,  and  the  disease  of  the  appendix  is  secondary. 

3.  Cases  in  which  the  disease  of  the  pelvic  organs  and  the  disease  of  the  appen- 
dix  are   independent   of   each   other. 

In  cases  falling  under  the  third  class,  namely,  those  in  which  disease  of  the 
appendix  and  disease  of  the  pelvic  organs  exist  independently,  and  their  asso- 
ciation is  purely  fortuitous,  the  affection  of  the  appendix  is,  as  a  rule,  an  old 
one.  The  appendix  will  be  found  attached  to  adjacent  structures,  or,  as  I  have 
often  seen  it,  in  the  course  of  gynecological  operations,  completely  atrophied 
and  even  reduced  to  a  fine  cord,  in  some  instances  no  more  than  a  filament. 
On  the  other  hand,  unsuspected  disease  of  the  uterus,  tubes,  or  ovaries,  asso- 
ciated with  the  remains  of  an  old  pelvic  peritonitis,  may  be  of  long  standing 
and  only  discovered  unexpectedly  during  the  course  of  an  operation  for  acute 
appendicitis.  It  is  not  always  an  easy  matter,  in  inflammatory  cases,  to  decide 
whether  disease  of  the  appendix  and  the  right  tube  and  ovary  are  independent 
or  associated,  for  extensive  inflammatory  affections  proceeding  from  the  vermi- 
form appendix  or  from  the  uterine  tube  may  spread  from  one  organ  to  the  other 
and  then  subside,  leaving  traces  behind  in  the  form  of  adhesions,  enveloping 
both  organs.  In  these  circumstances  reliance  must  be  placed  on  the  history  of 
the  case,  which  should  always  be  carefully  investigated. 

In  my  clinic  at  the  Johns  Hopkins  Hospital  I  have  had  occasion  to  remove 
the  appendix  in  240  cases,  in  the  majority  for  combined  gynecological  and  appen- 
dical disease.  Prior  to  1895,  appendical  adhesions  observed  during  the  course 
of  a  gynecological  operation  were  often  released  and  the  appendix  left  in  situ, 
but  it  is  now  my  invariable  custom  to  remove  the  appendix  in  these  cases,  unless 
the  condition  of  the  patient  absolutely  interdicts  the  slight  additional  strain. 
An  analysis  of  the  cases  in  which  the  appendix  was  removed  is  as  follows: 


700  APPENDICITIS   AND   GYNECOLOGICAL   AFFECTIONS. 

Acute  or  chronic  appendicitis  not  associated  with  gynecological 

affections 96  cases 

Appendicitis  associated  with  inflammation  of  the  pelvic  or- 

gans 64     " 

Appendicitis  associated  with  retroflexion  of  the  uterus  (some- 
times  adherent  I 11      " 

Appendicitis  complicating  ectopic  gestation 7     " 

Appendicitis  associated   with  tuberculosis  of  the  tubes  and 

with  secondary  tubercular  invasion  of  the  appendix 4     " 

Appendicitis  associated  with  tuberculosis  of  the  tubes,  with 

simple  adhesions  of  the  appendix   3     " 

Primary  tuberculosis  of  tlie  appendix 1  rase 

Appendix  adherent  to  ovarian  cysts 19  cases 

Appendix  adherent   to  ovarian  myoinata    1.5      " 

Appendix  adherent  to  malignant  ovarian  tumors,  with  secon- 
dary   invasion  of  the  appendix 2     " 

Appendix  adherent  to  malignant    tumors,   with   simple  adhe- 
sions of  the  appendix 1  case 

Primary  malignant  disease  of  the  appendix   1     " 

In  the  remaining  16  cases  the  appendix  was  removed  either  as  a  prophylactic 
measure,  or  (in  three  instances)  on  account  of  obscure  pain  in  the  right  abdo- 
men, without  apparent  disease. 

Appendicitis  Associated  with  Secondary  Pelvic  Inflammatory  Diseases. — 
Pelvic  inflammation,  the  result  of  direct  propagation  from  a  right  iliac  abscess, 
is  a  common  event,  and  is  apparently  more  frequent  in  women  than  in  men, 
probably  owing  to  the  greater  number  of  cases  in  which  the  appendix  occupies 
the  pelvic  position  in  women.  As  I  have  previously  insisted,  however,  a 
pelvic  abscess  may  form  with  an  appendix  high  up  in  the  iliac  fossa.  The 
great  significance  of  this  accident  in  women  is  that  the  uterus  and  its  adnexa, 
particularly  on  the  right  side,  may  become  implicated  in  the  suppurative  process 
with  a  resulting  permanent  impairment  of  their  functions.  Pus  tubes  and 
ovarian  abscesses  are  not  infrequent  sequela'  of  suppurative  appendicitis,  and  in 
less  severe  cases  the  pelvic  organs  remain  bound  up  in  adhesions  which  are  a 
frequent  cause  of  persistent  pelvic  pain,  severe  dysmenorrhea,  and  sterility.     A 

I  example  of  the  late  effects  of  a  suppurative  peri-appen<  licit  is  (KruGER, 
'/.lit.  f.  Chir.,  1^07.  Bd.  4.">i  was  the  case  of  a  woman,  thirty-two  years  old, 
who  was  admitted  with  a  pelvic  disease,  the  result  of  several  attacks  of  ap- 
pendicitis. The  appendix  was  removed  and  the  abscess  drained,  the  result 
being  that  the  patient  was  cured  of  the  appendiceal  trouble,  but  left  with  the 
uterus  fixed  in  retroposition,  while  the  tubes  and  ovaries,  especially  the  right 
one,  were  fixed  deep  in  the  pelvis. 

Barnsby  (These  fir  f.i/on.  1S98)  relates  the  case  of  a  woman,  aged  twenty- 
five  years,  who  gave  no  history  of  previous  pelvic  trouble,  but  had  suffered  from 


PELVIC    INFLAMMATION    SECONDARY   TO    APPENDICITIS.  701 

three  attacks  of  appendicitis,  the  second  and  third  terminating  in  the  discharge 
of  pus  per  rectum.  Operation  revealed  a  perforated  appendix  opening  into  an 
old  inflammatory  focus.  There  was  an  old  abscess  in  Douglas'  cul-de-sac,  com- 
municating with  the  rectum;  double  salpingitis,  most  pronounced  on  the  right 
side;  and  the  left  ovary  was  adherent  and  sclero-cystic.  The  appendix  and 
right  tube  were  removed  and  it  was  then  found  necessary  to  extirpate  the  uterus 
to  insure  drainage. 

One  of  my  cases  (Johns  Hopkins  Hospital;  Gyn.  Xo.  6502)  was  as  follows: 

The  patient,  who  had  had  five  normal  childbirths,  gave  no  history  of  pelvic 
disease.  While  in  perfect  health  she  was  suddenly  seized  with  severe  ab- 
dominal pain,  nausea  and  vomiting,  and  slight  fever.  The  next  day  a  lump 
appeared  in  the  right  side.  She  was  in  bed  one  month,  and  afterward  suffered  from 
pain  in  the  right  side  which  caused  her  to  limp.  Five  months  later  there  was  a 
sudden  exacerbation  of  the  pain,  attributed  by  the  patient  to  the  onset  of  the  men- 
strual period ;  it  soon  subsided,  but  fearing  to  precipitate  another  attack,  she  re- 
mained in  bed  until  entering  the  hospital  five  weeks  later.  At  operation  the  pelvis 
was  found  entirely  walled  off  from  the  abdominal  cavity  and  there  was  evidence 
of  recent  peritonitis  involving  the  adjacent  intestinal  loops.  Neither  uterus  nor 
tubes  were  visible.  The  appendix  was  visible  only  at  its  base,  the  tip  extending 
into  the  plastic  lymph  walling  off  the  pelvis.  On  bimanual  examination  per  vaginam 
and  through  the  opened  abdominal  cavity  the  uterus  could  be  felt,  but  no  mass  sug- 
gesting the  condition  seen  above.  The  adherent  bowel  was  freed  and  the  general 
peritoneal  cavity  packed  off  with  gauze.  The  pelvic  adhesions  were  carefully  sepa- 
rated, the  uterus  being  first  freed.  When  the  appendix  was  freed,  pus  was  seen 
oozing  from  it.  It  was  brought  out  and  removed.  The  right  tube  and  ovary  were 
then  inspected:  the  latter  was  found  to  be  normal,  but  the  tube  was  swollen  and 
engorged  and  its  mesentery  much  thickened;  it  was.  therefore,  removed.  As  no 
streptococci  were  found  in  the  exudate,  the  cavity  was  thoroughly  cleansed  with 
salt  solution  and  the  abdomen  closed  without  drainage.  Convalescence  was  abso- 
lutely smooth.  Examination  before  discharge  showed  a  natural  abdomen;  there 
was  no  resistance  in  the  right  pelvis,  but  on  the  left  side  slight  bands  of  adhesions 
and  an  indefinite  sense  of  resistance.     I  would  now  drain  such  a  case. 

Zweifel  especially  directs  attention  to  cases  of  appendicitis  with  a  purulent 
exudate,  which,  sinking  into  the  pelvis,  involves  the  tubes,  and  by  sealing  the 
abdominal  ostia  produces  sterility.  Duhrssen,  Shoemaker,  Siiober,  and 
others  believe  that  the  perimetric  adhesions  clue  to  appendicitis  are  a  frequent 
cause  of  uterine  displacements.  In  five  out  of  the  eleven  cases  in  which  I  found 
appendical  disease  associated  with  retroflexion,  the  uterus  was  bound  down  by 
light  adhesions  which  could  not  be  accounted  for  by  pelvic  infection,  and  the 
uterine  tubes  were  quite  healthy.  In  these  cases  it  was  probable  that  an  old 
appendicitis  had  been  the  cause  of  the  perimetritis. 

Unilateral  disease  of  the  adnexa  is  more  commonly  produced  by  appendic- 
itis  than  bilateral  affections.     In  exceptional  instances,  where  a  long  appen- 


702  APPENDICITIS   AND  GYNECOLOGICAL   AFFECTIONS. 

dix  descends  into  and  across  the  pelvis,  the  lefi  tube  and  ovary  arc  implicated. 
As  a  rule,  however,  the  right  adnexa  are  attacked,  the  left  remaining  perfectly 

healthy.  In  many  of  these  cases  the  appendical  origin  of  the  infection  is  clear, 
both  from  the  clinical  history  of  the  trouble  and  from  the  appearance  of  the 
organs  at  operation. 

T.  II.  Hawkins  (Med.  Rec.,  May  0,  1899)  describes  two  cases,  observed  in 
young  girls,  in  which  there  was  no  history  of  pelvic  trouble,  and  which  presented 
a  typical  clinical  picture  of  acute  appendicitis;  operation  showed  the  inflamed 
appendix  caught  up  in  the  fimbriated  end  of  the  right  tube,  and  a  secondary 
acute  purulent  inflammation  of  the  tube. 

A  very  interesting  case  is  related  by  1!.  Morison  (Lancet,  1001,  vol.  1,  p.  533). 

A  young  woman,  aged  twenty-seven  years,  was  admitted  to  the  Royal  Infirm- 
ary. Newcastle,  with  a  history  of  five  days'  illness,  beginning  with  sudden  pain  in 
the  epigastrium,  accompanied  by  vomiting.  Two  days  later  the  pain  settled  in 
die  righl  iliac  region.  The  pain  and  vomiting  continued,  and  on  the  third  and  fourth 
days  there  was  dysuria.  <  >n  admission,  the  patient  looked  flushed;  her  tempera- 
ture was  100.8°  F.;  her  pulse  120.  The  whole  abdomen  was  slightly  distended, 
tender,  and  rigid,  and  the  note  over  the  whole  lower  abdomen  was  dull.  Rectal 
examination  was  negative.  Ten  days  later  there  was  an  escape  of  fetid  pus  from 
the  cervix  uteri.  At  operation,  about  the  end  of  the  third  week  of  illness,  the  pouch 
of  1  >ouglas  was  found  to  be  practically  converted  into  a  large  abscess  which  extended 
upward  into  the  left  iliac  fossa.  A  fecal  concretion  was  found  in  the  abscess,  and 
mi  drawing  the  cecum  forward  the  whole  appendix  was  seen  to  have  sloughed  off, 
leaving  an  opening  into  the  cecum  the  size  of  a  sixpenny  piece.  The  right  side 
of  the  abscess  had  been  drained  by  the  Fallopian  tube,  which  was  thickened,  but 
pervious,  and  contained  fetid  pus  in  the  lumen.  The  opening  into  the  cecum  was 
sutured,  the  right  tube  removed,  and  a  large  drain  inserted.  Recovery  was  com- 
plicated by  the  development  of  a  vaginal  fecal  fistula,  but  the  patient  was  discharged 
well  at  the  end  of  six  weeks.  Examination  a  year  later  showed  no  adhesions  or  other 
abnormality  in  the  pelvis. 

The  importance  of  recognizing  the  presence  of  pelvic  complications  is  seen 
in  the  following  case.  The  patient,  an  unmarried  woman,  forty  years  old,  was 
admitted  with  acute  appendicitis.  At  operation  there  was  no  abscess  and  no 
pus  nor  fluid  in  the  general  cavity.     A  mass  felt  in  the  pelvis,  supposed  to  be 

an  enlarged  right  ovary,  was  not  disturbed.  There  was  slight  pain  and  disten- 
tion after  operation,  which  on  the  third  day  began  to  increase  somewhat,  and 
the  general  condition  was  rather  alarming;  face  flushed,  pulse  130,  temperature 
100°  F.,  respirations  difficult.  The  wound  was  reopened  ami  a  large  pelvic  abscess 
was  opened  and  drained.  The  mass  which  was  felt  at  the  first  operation  was 
also  explored  and  found  to  be  a  tubo-ovarian  abscess.  Death  occurred  the  fol- 
lowing day. 

In  many  instances  it  is  difficult  to  determine  the  origin  of  the  infection. 
The  fact  that  the  pelvic  disease  is  limited  to  the  right  side  is  suggestive  confirma- 


APPENDICITIS    SECONDARY    TO    PELVIC    DISEASE. 


703 


tory  evidence  of  the  append ical  origin,  but  the  chief  reliance  must  be  placed  on 
the  history  and  on  the  condition  found  at  operation. 

Appendicitis  Secondary  to  Pelvic  Inflammation. — In  the  majority  of 
instances  in  which  there  are  coexisting  affections  of  the  pelvic  organs  and  the 
appendix  the  primary  infection  is  in  the  pelvis.  As  a  rule,  the  appendix  is 
merely  adherent  by  its  distal  portion,  but  more  or  less  extensive  pathological 
changes  in  its  walls  are  frequently  found.  The  appendix  in  women,  as  we  have 
said,  frequently  occupies  the  pelvic  position  and  is  in  contact  with  the  upper 
portion  of  the  right  broad  ligament.  In  such  a  case  a  peri-salpingitis  readily 
involves  the  peritoneal  surface  of  the  appendix.  Moreover,  in  puerperal  infec- 
tion and  in  gonorrheal  salpingitis,  when  the  large  tube  is  higher  than  usual, 
the  appendix  may  be  in- 
volved even  when  situated 
above  the  pelvis.  In  a  case 
described  by  Barxsby  (loc. 
cit.)  the  large,  firm,  turgid 
appendix  was  densely  ad- 
herent to  the  posterior  sur- 
face of  an  enormous  tubo- 
ovarian  abscess  which  ex- 
tended almost  to  the  um- 
bilicus. Usually,  as  I 
have  said,  the  appendix  is 
attached  to  the  tubo-ova- 
rian  mass  merely  by  more 
or  less  firm  adhesions; 
sometimes  by  a  delicate 
strand  of  tissue  extending 
from  the  tip  of  the  appen- 
dix to  the  pelvic  mass,  the 
appendix    itself     showing 

practically  no  gross  changes.  But  careful  examination  of  such  appendices  shows 
that  comparatively  few  are  perfectly  healthy,  a  mild  catarrhal  inflammation 
being  most  often  met  with.  More  severe  lesions,  however,  are  not  unusual, 
an  unsuspected  acute  diffuse  inflammation  being  found  in  some  instances  at 
operation;  but  more  often  a  chronic  inflammation  or  various  residual  conditions, 
viz.,  strictures,  obliteration,  or  rystie  distention,  are  present. 

In  the  case  represented  in  big.  354  the  patient  had  had  the  left  ovary  removed 
two  years  before  for  inflammation,  dating  from  her  second  confinement  nine 
years  previously.  The  pain,  however,  continued  in  both  sides  of  the  abdomen. 
but  was  more  intense  in  the  right  side.  Operation  revealed  a  large  inflammatory 
tubo-ovarian  mass  in  the  right  side,  with  the  thickened,  chronically  inflamed 
appendix  densely  adherent  over  its  surface.     In  another  case  (Gyn.  No.  9560) 


Fig.  354. — H.A.Kelly.     Inflamed  Appendix  Adherent  to  a  Tubo- 
ovarian  Abscess.     (Gyn.  Path.  No.  5622.) 


701 


APPENDICITIS   AND   GYNECOLOGICAL   AFFECTIONS. 


the  patient  had  suffered  for  fifteen  years  (since  her  last  pregnancy)  from  leucor- 
rhea  and  neuralgic  pains  in  her  thighs  and  legs,  and  from  constipation.  There 
was  no  history  of  appendicitis.  At  operation  an  old  inflammatory  condition 
of  the  pelvic  organs  was  found.  The  right  tube  was  irregularly  distended  with 
clear  fluid,  its  surface  was  covered  with  dense  adhesions,  and  showed  many 
sub-peritoneal  cysts.  'The  appendix  was  densely  adherent  to  the  uterine  tube 
by  its  mesentery,  which  also  contained  a  small  peritoneal  cyst  (see  Fig.  355). 
In  one  of  my  cases  (Gyn.  No.  3650)  a  left  pyosalpinx  was  removed,  but  as 


Fig.  355. — H.  A.  Kelly.     Obliterated  Appendix  Adherent  to  a  Chronic  Tubo-ovarian   Inflammatory 

Mass.      (Gyn.    Path.    No.   5742.) 


the  right  tube  was  free  and  only  slightly  reddened,  it  was  left  in  -situ.  The 
patient  was  discharged  apparently  well.  A  few  days  later,  however,  she  returned 
with  a  mass  on  the  right  side.  Operation  showed  the  tube  distended  with  pus, 
ami  the  reddened,  fluctuant  appendix  adherent  to  it.  Removal  of  the  tube 
and  appendix  resulted  in  complete  cure. 

The  causal  relation  of  the  pelvic  disease  to  the  appendical  inflammation  may 
be  direct  or  indirect.  In  the  first,  the  appendix  in  the  beginning  becomes  in- 
volved in  the  pelvic  exudate,  the  adhesions  thus  formed  become  organized,  and 


APPENDICITIS    SECONDARY   TO    PELVIC    DISEASE.  705 

then,  lymph  and  blood-vascular  connections  being  established  between  the 
appendix  and  the  tube,  the  infection  is  easily  transmitted.  It  seems  probable, 
however,  that  usually  the  pelvic  disease,  by  fixing  the  appendix  in  adhesions, 
limits  its  movements,  and  by  inducing  stasis,  acts  as  a  predisposing  factor  in  the 
development  of  the  appendicitis.  The  bacteriologic  proof  of  the  mode  (if  infec- 
tion is  generally  unsatisfactory,  as  an  old  pelvic  inflammatory  focus  is  often 
secondarily  invaded  by  the  bacillus  coli,  and  streptococci  are 
present  in  most  acute  appendicitides.  In  a  case  in  my  clinic  reported  by  H. 
Robb  (John*  Hopkins  Hospital  Bull.,  1892),  in  which  there  was  a  history  of 
pelvic  disease,  and  at  operation  double  pus  tubes  were  found  with  the  inflamed 
appendix  adherent  to  the  one  on  the  right  side,  the  fact  that  a  pure  culture  of 
streptococcus  was  obtained  from  both  the  tube  and  the  appendix  sug- 
gests the  direct  infection  of  the  appendix  from  the  tube. 

The  history  of  the  onset  and  course  of  the  disease  is  the  most  important 
point  in  determining  its  o  iginal  focus.  It  is  frequently  possible  to  obtain  a 
clear  history  of  puerperal  or  gonorrheal  infection  accounting  for  the  pelvic  dis- 
ease, and  in  these  cases,  as  a  rule,  clinical  evidence  of  the  appendical  complica- 
tion is  conspicuously  absent. 

Tuberculosis  of  the  pelvic  organs  not  infrequently  involves 
the  appendix  in  the  peritoneal  adhesions  which  usually  accompany  this  condi- 
tion, and  in  a  number  of  these  cases  the  appendical  walls  are  invaded  by  the 
tubercular  process,  even  where  there  is  no  evidence  of  other  extension  of  the  dis- 
ease. Out  of  7  cases,  examined  by  myself,  in  which  the  appendix  was  adhe- 
rent to  the  tubercular  tube,  in  4  the  appendix  was  slightly  infiltrated  with  tuber- 
cles. A  circumscribed  tubercular  peritonitis  was  present  in  only  one  of  these 
instances.     These  cases  are  more  fully  considered  in  Chap.  XXXII. 

Tumors  of  the  uterus  and  ovaries,  complicated  by 
disease  of  the  appendix.  Cases  in  which  the  appendix  is  adherent 
to  cysts  of  the  right  ovary  are  frequently  observed,  and  occasionally  it  is  found 
attached  to  a  left  ovarian  cyst  (see  Fig.  356).  Out  of  about  300  operations  for 
cystoma  in  the  Johns  Hopkins  Hospital,  the  appendix  was  found  adherent  to 
tumors  of  the  right  side  in  16  cases,  and  to  those  of  the  left  side  in  3.  In  some 
instances  the  appendix  is  merely  secondarily  involved  in  the  general  adhesions 
which  so  frequently  surround  pelvic  tumors  and  are  the  residue  of  an  old  wide- 
spread peritoneal  reaction.  Dermoids,  and  cysts  with  torsion 
of  the  p  e  d  i  c  1  e  are  particularly  liable  to  give  rise  to  general  adhesions, 
and  it  is  in  such  cases  that  the  appendix  is  most  often  involved.  In  our  series 
the  cyst  had  become  twisted  on  its  axis  in  one-fourth  of  the  cases,  and  in  these 
the  appendical  adhesions  were  unusually  dense  and  extensive.  In  other  instances 
the  appendix  is  adherent  to  the  otherwise  smooth  surface  of  the  cyst,  or  to  the 
broad  ligament.  The  cause  of  the  formation  of  such  adhesions  is  not  always 
clear.  It  is  probable,  however,  that  the  direct  mechanical  influence  of  the 
tumor,  by  disturbing  the  relations  of  the  appendix,  by  interfering  with  its  circu- 
45 


700 


AIM'FXDK  HIS     \M)    (lYXKi'OUHIK'AI,     \  FFK<  Tl(  >XS. 


lation,  or  by  direcl  pressure,  has  indirectly  excited  a  mild  diffuse  inflammation 
of  die  appendix  with  extension  to  the  peritoneum.  It  is  readily  seen  how  such 
an  effect  would  he  produced  when  the  appendix  occupies  the  pelvic  position 
and  is  subject  to  direct  pressure  of  the  tumor.  In  some  cases  the  tip  only  is 
adherent  ;  in  others  the  entire  appendix,  including  its  niesenten  .  i-  plastered  to 
the  surface  of  the  tumor.  The  organ  itself  may  lie  practically  normal,  but, 
as  a  rule,  its  walls  are  thickened  and  rigid,  while  kinks,  twists,  strictures,  and 
other  results  of  an  inflammatory  process  are  commonly  found.     In  two  instances 


-ut.ov.Kg. 


■  vtrm.jpf). 


H.Be-'keJr  j<& 


Fig.  356. — H.  A.  Kelly.     Tip  of  the  Appendix  Adherent  to  Small  Dermoid  Cyrt  of  Left  Side. 
Note  also  omental  adhesions  above.     Appendicitis,  cholecystitis.     S.,  age  fifty-four,  Feb.  0,   1899.     Recovery. 

of  ovarian  cysts  I  found  the  appendix  stenosed  near  its  base,  and  the  remainder 
converted  into  a  large  transparent  cyst.  Acute  appendicitis  may  develop 
and  cause  secondary  infection  of  the  cyst  wall.  In  3  cases  described  by 
X.  <).  Werdeh  (Jour.  Amer.  Med.  Assoc,  Jan.  1,  1898)  acute  appendicitis 
complicating  ovarian  cysts  gave  rise  to  symptoms  simulating  torsion  of  the 
pedicle.  In  all  the  cyst  wall  was  congested  and  apparently  involved  in  a 
secondary  infection  from  the  appendix;  in  one,  the  sac  was  dark  and  exceedingly 
friable.  Wikf-rshaiskr  (cited  by  Pollak.  Centrbl.  f.  d.  Grenzb.  d.  Med.  u.  Chir., 
Bd.  7,  p.  161)  reports  a  case  of  large  suppurating  ovarian  cyst  with  firmly 
adherent  appendix,  and  was  of  opinion  that   the  infection  had  extended  from 


APPENDICITIS    COMPLICATING    PELVIC    DISEASE.  707 

the  appendix  to  the  tumor.  In  one  of  the  Johns  Hopkins  Hospital  cases  the 
appendix,  together  with  the  cecum,  was  attached  by  its  entire  length  to  a  sup- 
purating cyst  of  the  left  ovary. 

P  a  r  o  v  a  r  i  a  n  cysts  are  equally  disposed  to  be  complicated  by  appen- 
dical  adhesions,  or  by  acute  or  chronic  appendicitis.  In  a  case  described  by 
Kruger  (loc.  cit.,  Case  12)  the  patient,  a  girl  nineteen  years  old,  gave  a  history 
of  recurrent  attacks  of  appendicitis  extending  over  a  period  of  two  years.  When 
admitted,  during  the  third  severe  attack,  there  was  tenderness  in  both  hypo- 
gastric regions,  with  dulness  and  marked  resistance.  In  the  left  side  fluctuation 
was  detected.  At  operation  a  right  parovarian  cyst,  with  its  pedicle  twisted  two 
and  a  half  times,  was  found  lying  in  the  left  abdomen.  The  appendix,  which  was 
12  to  13  cm.  long,  deep  red,  and  injected,  descended  into  the  pelvis,  where  it  was 
adherent  by  its  tip.  In  the  case  of  malignant  ovarian  t  u  mors  the 
appendix  may  become  adherent  and  be  secondarily  invaded  by  the  new-growth. 
These  cases,  as  well  as  the  occurrence  of  metastatic  growths  in  the  appendix 
secondary  to  ovarian  tumors,  will  be  considered  in  Chap.  XXXI. 

Uterine  my  o  mat  a  are  less  frequently  complicated  by  disease  of 
the  appendix  than  ovarian  cysts.  In  some  500  myomectomies  the  appendix 
was  adherent  in  about  3  per  cent.  As  in  ovarian  tumors,  the  appendix 
usually  presents  evidence  of  chronic  inflammatory  changes.  In  one  case 
(Johns  Hopkins  Hospital,  Gyn.  No.  5302)  the  patient,  a  woman  forty-six  years 
old,  was  suddenly  seized  ten  days  before  admission,  while  enjoying  good 
health,  with  pain  in  the  right  lower  abdomen,  associated  with  dysuria  and  consti- 
pation. At  operation  the  large  myomatous  uterus  was  found  densely  adherent 
to  the  pelvic  floor,  the  sigmoid  flexure,  the  rectum,  and  the  colon,  while  the 
appendix  was  entirely  embedded  in  a  tubo-ovarian  abscess  on  the  right  side.  In 
another  case  Doleris  (Pollak)  removed  a  suppurating  myoma  per  vaginam,  death 
occurring  a  week  later,  when  the  postmortem  showed  a  perforated  gangrenous 
appendix  lying  in  the  centre  of  an  abscess,  encapsulated  amidst  coils  (if  intestine. 
Fig.  357  shows  the  appendix  adherent  to  a  large  uterine  myoma  which  exhibited 
sarcomatous  changes. 

Ectopic  gestation  is  complicated  with  appendicitis  in  a  consider- 
able number  of  cases.  Personally,  I  recall  seven  instances,  forming  about  10 
per  cent,  of  the  cases  of  extrauterine  pregnancy  observed  in  my  clinic,  in  which 
the  appendix  was  adherent  to  the  sac,  or  was  acutely  inflamed.  A  good  example 
of  the  simple  adhesion  of  the  appendix  to  a  tubal  pregnancy  is  shown  in  Fig. 
358.  In  this  case  the  patient  had  an  old,  inflammatory,  pelvic  disease  binding 
down  both  tubes  and  ovaries,  and  grafted  on  this,  an  extrauterine  pregnancy. 
with  adhesions  as  shown.  A  very  difficult  enucleation  was  done  by  bisection  (see 
Fig.  359).  The  patient  died  shortly  afterward,  seemingly  of  collapse.  The  great 
danger  in  these  cases  lies  in  the  infection  of  the  products  of  conception  by  the 
appendicitis.  Kbugeh  describes  the  case  of  a  woman,  aged  thirty,  with  a 
history  of  acute  appendicitis  beginning  four  weeks  previous  to  admission.     Men- 


708  APPENDICITIS   AND   GYNECOLOGICAL   AFFECTIONS. 

struation  was  regular;  her  temperature  was  DO. 1°  !•'.;  her  pulse  L20.     Incision 
in  the  right  Hank  exposed  the  abdominal  cavity  filled  with  large  clots.    The 


Fio.  357. — H.  A.  Kelly.     Appendix  Densely  Adherent  to  Fibroid  Tumor,  Undergoing  Sarcomatous 

Degeneration. 
Note  the  displacement  of  the  ileum  ami  the  adhesions  of  the  uterine  tube  ami  ovary.     Appendix  13  cm. 
luriK,  and  contained  many  small  concretions.     E.  M.,  age  fifty-six.     Death  without  operation.     Autopsy,  April 
24,1898.     (Path.  No    1085.)      (Natural  size.) 

thickened,  reddened  appendix  was  firmly  hound  to  the  gestation  sac,  and  it  was 
evident  that  infection  of  the  contents  of  the  hematocele  had  occurred.     Enucle- 


INDEPENDENT  AFFECTION'S  OF  THE  APPENDIX  AND  THE  PELVIC  ORGANS.    709 

ation  of  the  sac  and  the  appendix  was  followed  by  smooth  recovery.  A  very 
interesting  case  is  related  by  Summa  (St.  Louis  ('our.  of  Med.,  1000,  p.  434).  in 
which,  after  the  appendix  had  been  extirpated  at  an  operation  for  acute  perfora- 
tive appendicitis,  a  severe  hemorrhage 

suddenly  welled  up  from  the  depth  of 
the  pelvis.  Investigation  of  the  cause 
of  this  accident  revealed  a  fresh  rupture 
of  an  ectopic  pregnancy  on  the  left  side, 
a  one  month's  fetus  being  found. 

In  a  case  observed  in  the  Johns 
Hopkins  Hospital  (Gyn.  No.  457G)  the 
patient,  aged  thirty-eight  years,  entered 
with  a  history  of  having  fainted  one  week 
before,  while  hanging  up  clothes,  having 
since  had  continuous  hemorrhage.  As 
the  patient  was  subject  to  attacks  of 
syncope,  this  attack  did  not  alarm  her, 
and  was  ascribed  to  the  heat.  There  was  pain  about  the  umbilicus  and  in  the  in- 
guinal regions,  especially  the  right.     Temperature  100°  F. ;  pulse  100.     Operation 


Fig.  358. — Appendix  Adherent  to  Right  Broad 
Ligament  in  a  Right  Extrauterine  Preg- 
nancy. (M.  A.  Runycm.  Orange,  N.  J., 
Feb.    14,   1903.) 


Fig.  3.59. — Detailed  Study  or  the  Preceding  Showing  the  Right  Half  of  the  Bisected  Uterus,  the 
Ampulla  of  the  Uterine  Time  Distended  with  Clots,  and  hie  Appendix  Adherent  in  the  Angle 
Between  the  Ampulla  and  the  Isthmus.     (Natural  size.) 


showed  a  recently  ruptured,  right  tubal   pregnancy,  and  an  acutely  inflamed 
appendix. 

Independent  Affections  of   the  Appendix  and   the   Pelvic    Organs. — The 


710  APPENDICITIS   AND  GYNECOLOGICAL   AFFECTIONS. 

possibility  of  the  coexistence  of  pelvic  and  appendical  disease  should  always  be 
borne  in  mind,  especially  in  cases  which  are  being  treated  for  pelvic  disease. 
The  cure  of  the  pelvic  affection  in  such  instances  has  disappointing  results,  and 
the  patient  continues  to  suffer  from  much  of  the  discomfort  and  pain  for  which 
she  was  treated,  relief  being  finally  obtained  only  upon  removal  of  the  appendix. 
A  good  example  is  the  ease  of  a  patient  who  came  under  my  care  suffering  from 
general  pelvic  discomfort  and  painful  menstruation.  I  made  a  median  incision 
and  found  the  uterus  retroflexed,  and  the  ovaries  adherent.     The  adhesions  were 

freed  and  the  uterus  suspended.  The  patient  was  little,  if  at  all,  improved  by 
my  treatment.  Some  months  later  she  was  operated  on  by  .J.  B.  Deaver  of 
Philadelphia,  who  removed  the  chronically  inflamed  appendix,  with  the  com- 
plete relief  of  all  her  previous  symptoms.  Wiggin  (N.  Y.  Med.  Jour.,  IS'.M) 
operated  upon  a  woman  for  double  pyosalpinx  and  general  pelvic  peritonitis 
resulting  from  puerperal  infection.  The  appendix  was  not  examined,  as  the 
intestinal  adhesions  were  light  and  easily  separated.  At  the  end  of  the  third 
day  after  operation,  the  patient  suddenly  presented  the  typical  symptoms  of 
acute  appendicitis,  and  at  operation  the  following  day  a  large  quantity  of 
fetid  pus  was  evacuated  while  the  adherent,  perforated  appendix  was  removed. 
The  author  believed  that  the  appendix  was  diseased  at  the  time  of  the  pre- 
vious   operation    and    that    the   trauma  during   the   operative  manipulations 

had  excited  the  acute  attack.  DELAGENIERE  (Congrte  (le  cliir.,  ISO") 
relates  the  case  of  a  woman  who  had  had  the  right  ovary,  which  was  sclero- 
cystic,  removed,  and  the  uterus  suspended,  on  account  of  pain  in  the  abdo- 
men coincident  with  (lie  menstrual  periods  which  dated  from  a  childbirth 
five  years  before.  Six  weeks  later  she  was  attacked  with  symptoms  of  appen- 
dictis,  and  shortly  afterward  had  a  second  attack.  Operation  revealed  an 
adherent  and  chronically  ulcerated  appendix,  associated  with  the  presence  of  con- 
cretions. In  a  case  at  the  Johns  Hopkins  Hospital  the  patient  gave  a  history  of 
severe  pain  in  the  abdomen  ami  hack,  beginning  shortly  after  her  marriage,  two 
months  previously,  and  accompanied  by  leucorrhea  and  painful  menstruation. 
One  week  before  admission  she  began  to  suffer  from  cramp-like  pains  in  the 
abdomen  extending  down  the  thighs,  accompanied  with  painful  defecation  and 
dysuria.  At  operation,  double  pyosalpinx  was  found,  and  the  appendix,  which 
was  free  and  in  the  righl  iliac  fossa,  was  acutely  inflamed,  hard  and  rigid. 
Quite  often,  after  the  removal  of  uterine  or  ovarian  tumors,  which  are  not 
complicated  by  adhesions,  investigation  of  the  cecal  region  will  reveal  the  pres- 
ence of  independent  appendical  disease.  Thus,  in  one  case  after  removing  a 
non-adherent  ovarian  cyst,  I  found  the  appendix  converted  into  a  translucent, 
cucumber-shaped  cyst.  In  a  case  of  myoma,  the  appendix  was  found  com- 
pletely filled  and  distended  by  two  large  concretions;  in  another  case  of 
myoma  the  appendix  was  obliterated  and  enveloped  in  adhesions.  In  cases 
of  ectopic  gestation  the  association  of  an  independent  appendicitis  has  been 
frequently  observed,  as  in  the  case  of  Summa,  mentioned  above. 


DIAGNOSIS    BETWEEN   APPENDICITIS   AND    DISEASE   OF   PELVIC   ORGANS.    711 

DIAGNOSIS. 

The  greatest  interest  in  regard  to  the  relationship  existing  between  disease 
of  the  pelvic  organs  and  appendicitis  centres  in  the  diagnosis.  The  questions 
to  be  determined  are:  Is  the  case  one  of  pel  vie  d  is  ease;  is  it  one 
of  appendicitis;  or  is  it  one  of  coincident  appendical  and 
pelvic  disease?  In  many  instances  the  differential  diagnosis  is  of  interest 
chiefly  from  its  bearing  upon  the  technic  of  the  operation,  as  in  any  case  surgical 
intervention  is  imperative,  but  in  other  cases  it  is  of  the  utmost  importance 
that  a  correct  diagnosis  should  be  made;  as,  for  example,  if  we  are  dealing  with  a 
case  of  early  acute  salpingitis,  palliative  treatment  may  be  indicated ;  whereas, 
if  it  is  a  case  of  acute  appendicitis,  conservative  treatment  may  result  in  the 
death  of  the  patient. 

I  n  f  1  a  m  m  a  t  o  r  y  diseases  of  the  r  i  g  li  t  u  t  e  r  i  n  e  a  d.n  e  x  a 
are  most  frequently  confounded  with  appendicitis.  With  an  accurate  history 
of  the  onset  of  the  malady  and  a  careful  physical  examination,  mistakes  should 
seldom  occur,  since  both  diseases  present  such  characteristic  differences.  In 
the  history  of  the  development  of  acute  pelvic  infection  it  will  usually  be  found 
that  there  has  been  a  yellowish  vaginal  discharge,  often  associated  with  burning 
micturition,  for  a  longer  or  shorter  period  before  the  acute  symptoms  appeared; 
whereas  in  appendicitis  a  history  of  previous  attacks  of  pain  in  the  right  side,  or 
of  digestive  disturbances  is  often  given.  Abdominal  pain  associated  with  nausea 
and  vomiting  may  appear  as  suddenly  in  disease  of  the  adnexa  as  in  appendicitis, 
and  there  may  be  local  pain  on  pressure  over  the  right  lower  abdomen;  but 
the  local  pain  and  tenderness  are  usually  situated  more  deeply  in  the  pelvis  and 
right  inguinal  regions,  the  most  intense  pain  being  elicited  on  deep  palpation  in 
the  region  of  Poupart's  ligament.  On  vaginal  examination  exquisite  tenderness 
is  felt  on  one  or  the  other  side  of  the  uterus.  If  the  tenderness  is  equal  on  both 
sides  or  if  it  is  most  marked  on  the  left  side,  perimetritis  is  suggested.  It  is, 
however,  in  just  those  cases  where  the  appendix  occupies  the  pelvic  position, 
even  extending  to  the  left  side,  and  in  which  the  pain  and  tenderness  are  referred 
to  a  point  deep  down  in  the  pelvis  or  inguinal  region,  that  confusion  is  apt  to  exist. 
One  of  the  most  characteristic  differences  in  the  early  stage  of  the  attack  is  found 
in  the  character  of  the  pain,  which  at  the  onset  of  appendicitis  is  visually  parox- 
ysmal, while  in  pelvic  inflammation  it  is  more  steady  and  less  intense.  Fever, 
accelerated  pulse,  and  leucocytosis  offer  no  points  of  differentiation.  Chills 
are  more  common  in  appendical  inflammation,  but  are  very  inconstant.  The 
relation  of  the  attack  to  the  menstrual  periods  is  often  the  cause  of  error,  which 
sometimes  leads  to  a  fatal  delay  in  surgical  intervention.  The  two  following 
eases  illustrate  this  point. 

C.  K.  Lemon.  (Personal  communication.)  The  patient  was  seized  with  an  acute 
attack  of  appendicitis  associated  with  suppression  of  the  menstrual  flow,  on  the 


711'  AI'l'KXDlCITIS    AND    (iYNEI  OUH  111 '  \].     VFFECTIONS. 

second  day  of  the  period.  The  presence  of  pain  in  the  lower  abdomen  slight  fever, 
and  constipation  led  to  a  diagnosis  of  acute  congestion  of  the  uterus,  and  the  patient 
was  treated  with  laxatives  and  hot  applications.  When  seen  by  a  consultant  on 
the  fourth  day,  there  was  great  distention,  high  temperature,  and  complete  obsti- 
pation,  soon  followed  by  incessant  vomiting,  which  became  stercoraceous.  Death 
occurred  on  the  sixth  day.  An  important  clue  in  the  early  diagnosis  in  this  case 
was  the  history  <>f  several  previous  attacks  of  pain  in  the  lower  abdomen,  the  first 
of  which   antedated   the  beginning  of  the  catamenia. 

(I.  I.  McKelway.  {Med.  and  Surg.  Rip..  1892,  p.  603.)  A  young  unmarried 
woman  suffered  from  excruciating  pain  in  the  right  ovarian  region  at  every  men- 
strual period  and  constant  tenderness  on  pressure.  She  became  pale  and  weak 
and  was  unable  to  work.  A  vaginal  examination  showed  a  retroverted  uterus, 
bound  down  by  adhesions,  and  an  exceedingly  sensitive,  adherent  mass  the  size 
of  a  walnut,  to  the  right  of  the  uterus.  Abdominal  section  showed  an  adherent 
uterus,  a  normal  tube  and  ovary  on  the  left  side,  and  an  appendix  greatly  enlarged 
and  tense,  which  was  adherent  to  the  right  tube  and  ovary,  occasioning  the  sen- 
sitive mass  palpated  in  the  examination.  The  tube  and  ovary,  which  apart  from 
the  appendical  adhesions,  were  healthy,  were  freed  and  left  in  situ,  and  the  uterus 
was  freed.  The  appendix  was  removed  and  the  patient  made  a  perfect  recovery, 
with  the  uterus  in  its  normal  position  and  no  lateral  mass. 

The  development  of  pelvic  inflammation  in  a  young  girl  or  an  unmarried 
woman  of  good  character  should  always  arouse  the  suspicion  of  primary  appen- 
dical disease,  even  when  the  bimanual  examination  shows  definite  disease  of 
the  adnexa  on  one  or  both  sides,  as  in  many  cases  it  will  be  found  that  the  tubc- 
ovarian  disease  is  due  to  a  secondary  infection  from  the  appendix. 

In  the  early  stage  of  either  affection  a  tumor  cannot  usually  lie  detected: 
later,  a  more  or  less  well-defined  resistance  posterior  or  lateral  to  the  uterus 
may  signify  a  pelvic  inflammation  or  pelvic  appendicitis.  In  the  latter,  the 
resistance  is  usually  situated  higher,  extending  from  the  posterior  border  of  the 
rigid  broad  ligament  toward  the  iliac  fossa,  and  the  broad  ligament  itself  is  free. 
In  pelvic  disease  the  tumor  is  deep  in  the  pelvis,  and  it  i-  often  possible  to  palpate 
the  thickened  uterine  end  of  the  tube  and  to  trace  it  out  to  the  mass.  An  inter- 
esting case  related  by  Bvnxsnv  (he.  cit.)  is  as  follows: 

An  unmarried  woman,  twenty-five  years  old.  was  suddenly  seized,  when  in 
perfect  health,  with  severe  abdominal  pain,  vomiting,  constipation,  and  fever. 
The  abdomen  was  generally  sensitive,  but  especially  so  in  the  right  iliac  fossa, 
although  no  tumefaction  was  present.  On  the  sixth  day,  menstruation  appeared 
and  the  symptoms  subsided,  but  a  dull  pain  persisted  in  the  right  side,  and  on  this 
account  a  vaginal  examination  was  made  three  weeks  later.  The  uterus  was  found 
fixed  and  painful,  the  lateral  fornices  being  indurated  and  filled  with  a  mass  of  exu- 
date. ( )n  the  right  side  the  mass  seemed  glued  to  the  uterus.  The  iliac  fossa 
was  tender  but  free,  following  the  examination  menstruation  reappeared.  The 
general  condition  of  the  patient  then  improved.  During  the  next  two  years  similar 
attacks    occurred,  and   at    the    end  of    that    time   she   entered  the  hospital.     On 


DIAGNOSIS  BETWEEN  APPENDICITIS  AND  DISEASE  OF  THE  PELVIC  ORGANS.    713 

bimanual  examination  a  large  mass  was  found,  situated  toward  the  lower  part  of  the 
crural  arch,  apparently  descending  from  the  iliac  fossa  to  the  right  cul-de-sac,  and 
seemingly  independent  of  the  uterus.  On  account  of  the  intact  hymen,  the  resem- 
blance of  the  anterior  attacks  to  appendicitis,  the  absence  of  connection  between 
the  mass  and  the  uterus,  and  the  normal  left  adnexa,  a  diagnosis  of  appendicitis 
was  made.  The  day  after  the  examination,  however,  an  acute  exacerbation  oc- 
curred, and  a  second  examination  showed  the  mass  adherent  to  the  uterus  and 
completely  tilling  the  right  fornix.  The  diagnosis  was  then  changed  to  inflamma- 
tion of  the  right  adnexa.  Operation  revealed  a  voluminous  appendix,  with  thick- 
ened walls  which  contained  three  calculi.  It  was  adherent  by  its  tip  to  the  right 
side  of  the  uterus.     Removal  of  the  appendix  resulted  in  perfect  cure. 

In  other  cases  a  large  pyosalpinx  may  extend  up  into  the  iliac  fossa  and 
closely  simulate  an  appendiceal  abscess.  A  case  observed  at  the  Johns  Hopkins 
Hospital  in  which  the  clinical  history  and  physical  signs  were  very  confusing,  is 
the  following: 

J.  H.  H.,  Gyn.  No.  5750.  A  woman,  twenty-two  years  old.  was  admitted  with 
a  history  of  pain  in  the  right  iliac  fossa,  beginning  immediately  after  a  normal 
deliverv  six  weeks  before,  from  which  she  soon  recovered  and  was  able  to  attend 
to  her  usual  duties.  Three  weeks  later  she  was  suddenly  seized  with  severe  pain 
in  the  right  abdomen  and  at  the  same  time  a  swelling  was  discovered.  The  pain 
and  swelling  steadily  increased,  and  although  going  about,  the  patient  felt  ill  and 
weak.  On  admission,  the  right  leg  was  slightly  flexed  and  there  was  a  hard  tumor 
mass  in  the  right  iliac  fossa,  having  a  well-defined,  sharp  margin  toward  the  median 
line  of  the  abdomen  and  extending  down  to  the  upper  part  of  the  pelvis.  The 
temperature  was  100°  F. ;  the  pulse  100.  A  vaginal  puncture  was  first  attempted, 
but  the  mass  was  too  high  to  be  reached  easily.  An  incision  was  then  made  in 
the  right  linea  semilunaris  opening  over  the  mass,  which  was  found  to  consist  of 
several  small  pus  cavities  with  exceedingly  dense  walls,  which  appeared  to  contain 
the  right  tube  extending  up  from  the  cormi  of  the  uterus  toward  the  right  iliac  region 
and  the  umbilicus.  The  intestines  were  adherent  to  the  mass,  as  well  as  the  omen- 
tum on  the  inner  side.  The  right  ovary  and  the  left  appendages  were  free  and 
normal.     The  cavity  was  drained,  and  the  patient  made  an  uninterrupted  recovery. 

Acute  pelvic  i  n  f  1  a  m  m  a  t  i  o  n  a  c  c  o  m  p  a  n  i  e  d  w  i  t  h 
spreading  or  generaliz  e  d  p  eritonitis  in  the  absence  of  a  clear 
history,  cannot  usually  be  differentiated  from  appendicitis.  In  two  cases  ad- 
mitted to  the  Johns  Hopkins  Hospital  a  diagnosis  of  appendicitis  with  diffuse 
peritonitis  was  made,  but  at  operation  a  generalized  peritonitis  originating  from 
acute  gonorrheal  salpingitis  was  found. 

J.  H.  IT..  Surg.  No,  7760.  A  girl,  eighteen  years  old,  was  admitted  with  a  his- 
tory of  acute  abdominal  pain  beginning  suddenly  five  days  before,  and  accompanied 
with  nausea,  vomiting,  hiccough,  and  constipation.  The  pain  was  localized  from 
the  first  in  the  right  side.     On  admission  the  abdomen  was  not  distended;   there 


71  I  APPENDICITIS   AND   GYNECOLOGICAL   AFFECTIONS. 

was  no  tenderness  nor  muscle  spasm  on  the  left  side;  on  the  righl  there  was  marked 
tenderness,  most  pronounced  at  a  point  M  cm.  from  the  umbilicus,  mi  the  line  to 
the  righl  anterior  superior  spine  of  the  ilium.  There  was  slight  muscle  spasm  over 
this  area;  temperature  100°  F. ;  pulse  100;  leucocytes  34,000.  Bimanual  exam- 
ination caused  pain  in  the  above  area,  and  there  was  no  induration  in  the  vag- 
inal vault.  The  hymen  was  absent,  and  there  was  a  history  of  vaginitis  lor  six 
months.  Operation  revealed  a  general  tibrino-puruleiit  peritonitis  and  double 
gonorrheal  salpingitis.  The  tubes  were  removed  and  the  abdomen  closed  with 
a  small  drain.     Prompt  recovery  followed. 

.1.  H.  H.,  Surg.  No.  7710.  A  single  woman,  aged  twenty-five  years,  admitted 
exposure  to  infection  for  five  years  and  during  the  past  year  had  suffered  from 
slight  ardor  urince.  She  entered  with  a  history  of  acute  abdominal  pain  for  three 
days,  most  intense  in  the  left  side  and  epigastrium.  The  pain  was  constant  but 
subject  to  acute  exacerbations.  The  bowels  were  constipated  and  micturition 
was  painful.  The  patient  looked  flushed,  the  tongue  was  coated,  and  the  abdomen 
somewhat  full  in  the  umbilical  region.  Tenderness  was  most  marked  in  the  left 
flank,  in  the  epigastric,  and  in  both  hypogastric  regions.  Vaginal  examination 
was  negative.  The  temperature  was  102°  1-'.;  the  pulse  110;  the  leucocytes  19,000. 
( Operation  showed  a  general  plastic  fibrinous  peritonitis,  the  appendix  being  involved 
to  the  same  extent  as  the  rest  of  the  bowel;  the  tidies  were  not  thickened,  but 
acutely  inflamed,  and  contained  pus.  The  gonococcus  was  obtained  from 
the  peritoneal  exudate  in  both  cases. 

In  both  of  these  cases,  not  withstanding  the  definite  history  of  venereal  expo- 
sure, the  prominence  of  the  abdominal  symptoms  and  the  absence  of  pelvic 
symptoms  occasioned  a  wrong  diagnosis. 

In  another  case  diffuse  peritonitis  resulting  from  a  ruptured  right  pyosal- 
pinx  was  mistaken  for  acute  appendicitis.  SlEGEL  (cited  by  Pollak)  found  a 
ruptured  ovarian  abscess  at  operation  upon  a  case  in  which  a  diagnosis  of  perfo- 
rative appendicitis  had  been  made.  FenWICK  {Lancet,  1897)  reports  a  case  of 
ruptured  pyosalpinx  mistaken  for  appendicitis.  A  pelvic  abscess  whether 
originating  from  the  generative  organs  or  from  the  appendix,  presents  no  distinc- 
tive features,  and  in  either  c:\si-  there  maybe  a  complete  absence  of  abdominal 
pain  and  tenderness.  The  history  of  preceding  vulvo-vaginitis  or  of  puerperal 
infection  on  the  one  hand,  or  of  attacks  of  right  iliac  pain  on  the  other,  are 
most   important  guides  to  a  diagnosis. 

A.  E.  Gallant  (Amor.  Med.,  1903,  Xo.  1,  830)  describes  two  very  interesting 
cases  in  children,  one  ten  years  old,  the  other  thirteen,  in  which  a  retroperitoneal 
appendical  abscess  burrowed  down  in  the  recto-vaginal  septum  and  formed  a 
bulging  tumor  at  the  outlet.  A  diagnosis  of  pelvic  disease  was  made  and  laparot- 
omy performed,  but  in  each  case  the  pelvic  organs  and  peritoneum  were  abso- 
lutely healthy.  MuNDE  {Med.  News,  1897,  p.  621)  describes  a  similar  case; 
a  well-defined  elastic  swelling  in  the  median  line  of  the  abdomen  was  taken  for 
an  ovarian  cyst.  A  median  incision  showed  the  uterus  and  appendages  normal 
and  the  swelling  retroperitoneal.     The  incision  was  (dosed  and  a  vaginal  examina- 


DIAGNOSIS.  715 

tion,  neglected  before,  revealed  a  tense  protrusion  of  the  posterior  wall.  On 
opening  this,  a  large  quantity  of  fetid  pus  escaped,  and  a  probe  introduced  into 
the  abscess  cavity  passed  readily  up  to  the  crest  of  the  right  ilium. 

Confusion  in  the  diagnosis  between  appendicitis  and  ovarian  cyst,  with  torsion 
of  the  pedicle  is  very  common.  NiOT  (These  de  Paris,  1901)  cites  11  instances 
of  dermoid  cysts  with  twisted  pedicle,  mistaken  for  appendicitis.  In  2  out  of 
5  cases  of  cyst  with  twisted  pedicle  observed  by  Fowler,  the  patient  was  sent 
into  the  hospital  with  a  diagnosis  of  appendicitis.  As  a  guide  to  the  differential 
diagnosis  a  previous  knowledge  of  the  existence  of  the  tumor  is  of  the  greatest 
importance.  It  happens,  however,  that  acute  torsion  is  most  common  in 
the  case  of  cysts  of  medium  size,  which  had  not  previously  produced  any 
visible  swelling,  the  subjective  symptoms  being  absent  or  else  very  slight. 
The  frequent  association  of  constipation  with  pelvic  tumors  leads  rather  in 
the  wrong  direction  in  considering  the  diagnosis.  The  sudden  onset  of  severe 
pain,  often  accompanied  with  nausea  and  vomiting,  may  closely  simulate 
acute  appendicitis.  The  chief  distinguishing  features  of  torsion  of  an  ovarian 
pedicle  are  the  character  of  the  pain,  which  is  more  continuous  and  diffuse, 
unlike  the  colicky  initial  pain  of  appendicitis,  with  its  later  localization  in 
the  right  iliac  fossa.  At  a  later  stage  when  peritonitis  supervenes,  the  sub- 
jective symptoms  are  very  similar.  Palpation  is  the  most  valuable  means  of 
differentiation.  It  is  sometimes  possible  at  the  very  outset  to  distinguish  the 
rounded,  well-defined,  elastic  ovarian  tumor,  while  in  appendicitis  a  mass  is 
rarely  observed  in  the  early  stages,  and,  if  it  is,  has  not  the  sharp  contour  of  the 
cyst.  Fluctuation  in  the  case  of  dermoids  and  some  multilocular  cysts  is  often 
indefinite,  and  never  to  be  depended  upon.  In  many  cases,  however,  the  dis- 
tention and  extreme  sensitiveness  of  the  abdomen  render  palpation  very  unsatis- 
factory, and  the  cyst  ma}'  be  completely  masked  by  the  rigid  abdominal  walls. 
Percussion  may  then  be  serviceable  in  outlining  the  tumor.  As  the  early  acute 
reaction  subsides,  the  tumor  is  sometimes  readily  palpable;  whereas  in  appen- 
dicitis, not  complicated  with  diffuse  peritonitis,  the  abdomen  becomes  natural- 
looking  and  soft,  with  the  exception  of  the  appendical  region.  In  either  case, 
however,  peritonitis  may  complicate  the  situation.  In  this  event  a  differential 
diagnosis  is  sometimes  impossible,  but,  in  general",  it  may  be  noted  that  the  peri- 
tonitis accompanying  ovarian  cyst  is  of  a  milder  type,  and  is  not  associated  with 
the  severe  constitutional  symptoms  of  peritonitis  originating  from  appendicitis. 
Moreover,  the  abdominal  tenderness  is  usually  less  pronounced.  Examination 
]>cr  vaginam  and  per  rectum  will  sometimes  give  valuable  information  regarding 
the  malady,  and  it  may  in  this  way  be  possible  not  only  to  outline  the  cyst,  but 
also  to  recognize  the  twisted  pedicle,  which  is  felt  extending  from  the  side  of 
the  uterus  up  to  the  abdominal  mass.  If  the  tumor  is  entirely  intra-abdominal, 
the  uterus  may  be  displaced  upward.  As  in  either  condition  operative  inter- 
ference is  imperative,  the  differential  diagnosis  is  not  of  great  importance  except 
as  a  guide  to  the  incision:  and,  as  a  rule,  when  the  patient  is  anesthetized  the 


710  APPENDICITIS   AND   GYNECOLOGICAL    AFFECTIONS. 

tumor  is  easily  recognized  if  a  careful  bimanual  examination  is  made.  It  is 
advisable  in  making  the  rectal  examination  immediately  before  operation  to 
protect  the  hands  with  rubber  gloves. 

The  diagnosis  between  a  r  u  p  t  u  r  e  d  t  u  l>  a  1  \>  r  e  g  n  a  n  c  y  and  ap- 
pendicitis is  seldom  difficult,  it'  an  accurate  account  of  the  events  leading 
up  to   the  attack  can  lie  obtained,  as  well   as  a   clear  description  of  its  (inset. 

The  history  of  irregular  menstruation,  especially  the  statement  thai  a  period 
has  been  delayed  for  a  week  or  more,  with  a  subsequent  slight,  irregular  flow, 
is  very  suggestive  of  tubal  pregnancy.  The  onset  of  the  attack  with  sudden 
agonizing  pain,  followed  almost  immediately  by  fainting  and  marked  pallor, 
is  pathognomonic.  Chills,  vomiting,  and  sudden  evacuation  of  the  bowels,  may 
occur  at  the  onset  of  ruptured  tubal  pregnancy  or  with  acute  perforative  appen- 
dicitis. Tenderness  and  muscle  spasm  on  palpation  over  the  right  iliac  region 
may  be  observed  in  a  right  tubal  pregnancy;  usually,  however,  the  local  signs 
are  situated  deeper  in  the  pelvis.  On  bimanual  examination  the  enlarged  tube 
is  usually  easily  palpated.  Finally,  it  may  be  said  that  the  most  important 
point  in  arriving  at  a  correct  diagnosis  is  the  recognition  of  the  fact  that  confu- 
sion may  exist. 

Diagnosis  of  Coexisting  Affections. — An  important  question  to  be  deter- 
mined in  some  cases  in  which  the  presence  of  the  gynecological  affection  is  well 
recognized,  is  whether  there  is  a  complicating  appendicitis.  The  fact  that  the 
appendix  is  frequently  involved  in  pelvic  adhesions  is  now  too  well  known  to 
require  especial  emphasis,  and  at  the  present  time  it  is  improbable  that  such 
accidents  could  occur  as  were  reported  by  Tait  and  WlGGIN,  in  which,  during 
the  course  of  an  operation  upon  the  pelvic  organs,  the  appendix,  which  was  in- 
volved in  the  universal  dense  adhesions,  was  severed  without  the  knowledge 
of  the  operator,  the  fact  being  only  discovered  on  the  postmortem  table.  It 
must  be  remembered,  however,  that  independent  affections,  acute  or  chronic 
may  coexist,  and  that  one  may  be  masked  by  the  predominant  symptoms  of 
the  other.  This  is  of  especial  importance  in  the  case  of  acute  appendicitis 
developing  during  the  course  of  an  acute  pelvic  inflammation.  The  greater 
severity  of  the  abdominal  and  general  constitutional  symptoms,  the  paroxysmal 
pain,  and  the  localization  at  or  near  McBurney's  point,  should  suggest  this 
complication.  In  doubtful  cases  an  exploratory  section  entails  less  risk  than 
delaying  the  operation  until  the  diagnosis  is  clear.  Moreover,  when  pelvic  in- 
flammatory disease  is  attended  with  increasing  abdominal  [tain,  tenderness, 
and  rigidity,  operative  interference  is  usually  indicated.  An  abdominal  section 
is  preferable  to  the  vaginal  route  in  all  cases  where  there  is  a  possibility  of  error. 
Anite  appendicitis  occurring  in  a  patient  who  is  known  to  he  the  subject  of  an 
ovarian  cyst  would  naturally  suggest  a  torsion  of  the  pedicle,  as  in  three  cases 
recorded  by  Werdeb  (he.  cit.).  Fortunately  the  differential  diagnosis  in  such 
a  case  is  not  of  great  importance,  as  early  operation  is  indicated  in  either  case, 
and  the  condition  is  then  easily  recognized.     The  coexistence  of  appendicitis 


REMOVAL   OF   NORMAL   APPENDIX.  717 

and  extrauterine  pregnancy  is  usually  easily  recognized  if  a  careful  history  of 
the  case  is  obtained  and  a  thorough  abdominal  and  bimanual  examination 
made.  Both  affections  present  such  a  characteristic  clinical  history  that  even 
when  associated,  mistakes  should  not  often  occur.  The  greatest  danger  lies  in 
the  fact  that  when  an  acute  appendicitis  exists  at  the  same  time  as  an  unruptured 
tubal  pregnane}'  which  has  not  given  rise  to  any  pronounced  symptoms,  the 
operator  may  not  be  aware  of  its  presence.  In  one  case  of  a  young  unmarried 
woman,  giving  a  definite  history  of  recurrent  appendicitis,  there  was  also  a 
history  of  irregular  menstrual  flow  for  about  three  w'eeks,  and  on  vaginal  ex- 
amination the  tube  seemed  to  be  thickened.  After  removing  the  chronically 
inflamed  appendix  I  also  removed  an  early,  unruptured,  tubal  pregnancy. 


TREATMENT. 

Examination  of  the  Appendix  whenever  the  Abdomen  is  Opened. — The 
frequency  with  which  disease  of  the  appendix  is  associated  with  disease  of  the 
pelvic  organs  affords  a  sufficient  reason  for  examination  of  the  appendix  when- 
ever the  abdomen  is  opened  for  any  reason  whatever.  I  have  elsewhere  empha- 
sized the  duty  incumbent  upon  every  surgeon  of  utilizing  the  opportunity 
afforded  by  abdominal  section  to  examine  the  appendix  whenever  it  can  be  done 
without  additional  risk.*  For  the  last  eight  years  I  have  made  it  my  invariable 
practice  not  only  to  examine  the  appendix,  but  to  note  its  condition  as  regards 
length,  soundness,  and  freedom  from  adhesions,  including  these  data  among 
others  which  the  anesthetizer  is  expected  to  fill  in  upon  a  printed  slip. 

Removal  of  the  Appendix  as  a  Prophylactic  Measure. — The  first  quest  inn 
which  arises  at  this  point  is  whether  the  normal  appendix  should  be  removed  as 
a  prophylactic  measure  whenever  the  opportunity  to  do  so  is  afforded  by  abdom- 
inal section.  During  the  time  this  book  has  been  in  preparation  I  have  dis- 
cussed the  question  with  various  friends,  and  I  find  that  the  greatest  diversity 
of  opinion  exists  among  them  in  regard  to  it,  some  of  them  urging  the  radical 
plan  of  removal  in  every  ease,  and  others  condemning  such  a  practice  as  meddle- 
some and  unsurgical.  The  variance  of  opinion  among  men  of  equal  ability  and 
experience  was  indeed  so  striking  that  I  believed  it  would  be  both  of  use  and  of 
interest  to  investigate  and  make  known  the  views  of  a  number  of  professional 
men  upon  the  subject.  I  wrote,  therefore,  to  80  well-known  surgeons  in  different 
parts  of  the  United  States,  asking  for  their  opinions  and  requesting  permis- 
sion to  publish  them.  The  method  of  interrogation  which  I  used  was  to  send  each 
individual  a  return  postal  card  with  the  following  question:  When  the 
abdomen  is  opened  for  other  causes,  and  the  per- 
fectly normal  appendix  is  easily  accessible,  is  it 
y  o  u  r    r  u  1  e    to    remove    it'' 

*  "  The  exploration  of  the  abdomen  as  an  adjunct  to  every  celiotomy."  Med.  News,  Dec. 
16,  1899. 


718  APPENDICITIS   AND   GYNECOLOGICAL   AFFECTIONS. 

To  80  applications  I  received  74  replies,  which  have  been  published  else- 
where in  some  detail  [Jour.  Anter.  Med.  Assoc,  <  >ct.  25,  1902).  It  is  evident  from 
them  that  no  uniformity  of  opinion  exists  among  medical  men  as  to  the  condi- 
tions under  which  the  appendix  should  or  should  not  be  removed.  (  toe  surgeon 
of  ability  and  experience,  for  instance,  replies:  "Yes,  always";  while  another, 
whose  opinion  is  no  less  entitled  to  consideration,  answers  :  "  No,  it  is  unsurgical.  " 
The  categorical  form  of  my  inquiry,  of  course,  made  it  impossible  for  surgeons 
to  qualify  their  answers,  as  some  of  them,  apparently,  wished  to  do.  In  classi- 
fying the  replies,  1  tave  treated  answers  such  as  "  Usually,  but  not  always." 
or  "If  the  patient's  condition  permits."  as  unqualified,  since  1  asked  only  for 
the  rule,  not  the  exception;  and  1  assume  in  my  question  that  no  serious  contra- 
indication is  present.  A  few  answers,  however,  were  received  which  could  not  be 
classified  unreservedly  as  either  affirmative  or  negative. 

Exclusive  of  these,  there  were  70  replies.  44  of  which  were  against  remov- 
ing the  normal  appendix,  and  L'O  in  favor  of  doing  so. 

Assuming  these  results  to  represent  a  general  consensus  of  opinion  throughout 
the  United  States,  they  show  a  decided  majority  (44  to  26)  against  the  removal 
of  the  normal  appendix,  simply  because  the  opportunity  to  do  so  is  present. 
My  own  opinion  coincides  entirely  with  this  view.  I  never  remove  the  appen- 
dix in  the  course  of  an  operation  for  other  causes,  when  it  proves  on  inspection 
in  lie  entirely  normal;  and  my  reasons  for  this  position  are  as  follows: 

1.  The  removal  of  the  appendix  involves  a  slight  additional  risk,  owing  to 
the  fact  that  no  matter  how  good  the  patient's  condition  may  be  at  the  time  of 
the  removal  there  is  no  guarantee  that  it  will  remain  so  until  the  end  of  the 
operation;  and  should  a  condition  of  shock  ensue,  the  additional  five  minutes 
thus  consumed  will  lessen  the  patient's  chances  of  recovery. 

2.  We  are  not  as  yet  in  a  position  to  estimate  the  importance  of  removing 
the  normal  appendix  as  a  prophylactic  measure,  for  statistics  have  not  yet 
made  it  evident  what  is  the  exact  risk  of  an  attack  of  appendicitis  to  each  indi- 
vidual in  the  community. 

3.  The  fact  that  the  appendix  has  no  known  function  does  not  prove  that 
it  is  a  functibnless  organ,  although  we  are  in  the  habit  of  calling  it  so;  and  it 
is  within  the  bounds  of  possibility  that  an  increase  in  our  knowledge  concerning 
it  may  in  the  future  demonstrate  some  reason  for  its  preservation.  It  is  only 
a  few  years  since  the  ovaries  were  considered  to  have  no  vise  or  purpose  besides 
that  of  reproduction,  and  their  extirpation,  apart  from  interference  with  their 
primary  function,  was  a  matter  of  no  importance.  Now.  however,  when  their 
relation  to  the  process  of  internal  secretion  is  beginning  to  be  understood,  we 
find  ourselves  responsible  for  their  preservation  for  entirely  other  reasons. 

R  e  m  oval  of  the  A  d  h  e  r  e  n  t  A  p  p  e  n  d  i  x  . — I  availed  myself 
of  the  opportunity  afforded  by  the  above  inquiry  to  ascertain  also  the  opinion 
generally  held  as  to  the  advisability  of  removing  the  vermiform  appendix  when  it 
is  adherent,  or,  in  other  words,  when  it  deviates  in  the  slightest  degree  possible 


REMOVAL    OF    APPENDIX    AS    PROPHYLACTIC    MEASURE.  719 

from  normal.  I  appended  a  second  question  to  the  following  effect:  When 
the  appendix  is  even  slightly  adherent  to  neighbor- 
ing structures,  peritoneum,  ovarian,  or  fibroid  tu- 
mors, do  you  then  remove  it?  To  this  query  I  received  7  answers 
so  qualified  that  they  could  not  be  classified.  Out  of  the  remaining  i>7  answers. 
60  were  in  favor  of  removing  the  appendix  under  the  conditions  specified,  and 
7  were  against  it.  It  will  be  seen  that  the  majority  in  favor  of  removing  the 
appendix  under  the  conditions  is  very  large,  so  large  as  to  constitute  almost 
unanimity  of  opinion.  For  myself,  I  believe  it  to  be  an  excellent  general  rule  to 
remove  the  appendix  whenever  it  is  adherent  to  another  organ,  because  it  is 
prone  to  bleed,  and  if  returned  to  the  abdomen,  may  very  readily  contract  adhe- 
sions which  are  the  occasion  of  an  attack  of  appendicitis.  I  also  think  it  a 
good  special  rule  to  remove  any  appendix  which  hangs  free  from  the  end  of  the 
cecum,  as  well  as  one  which  is  long  enough  to  reach  the  field  of  an  adjacent 
operation,  because  such  appendices  are  specially  liable  to  become  adherent.  I  do 
not,  however,  remove  a  short  appendix,  nor  one  which  is  curled  up  on  either  side 
of  the  cecum,  and  I  w<  >ul<  1  carefully  avoid  pulling  out  an  appendix  which  lies  above 
the  horizontal  line  traversing  the  lower  end  of  the  cecum.  In  this  connection  I 
should  also  like  to  recall  and  to  endorse  the  opinion  of  R.  Abbe,  namely,  that 
the  perfectly  normal  appendix  never  contains  fecal  concretions,  therefore,  when- 
ever, an  apparently  healthy  appendix  is  felt  to  contain  these,  there  is  sufficient 
reason  for  its  removal. 

In  any  case  also  where  the  patient  specially  requests  that  the  appendix  lie 
removed,  I  think  the  surgeon  should  comply.  The  risk  of  the  operation, 
properly  done,  is  extremely  small,  and  it  is  sometimes  a  great  relief  to  a 
patient's  mind  to  know  that  it  has  been  removed,  especially  if  there  have 
been  other  cases  of  appendicitis  among  his  family  and  friends. 

Removal  of  the  Appendix  when  Operations  are  Performed  in  its  Neigh- 
borhood that  might  give  rise  to  Post-operative  Adhesions. — In  the  case  of 
men  there  is  practically  no  risk  that  disease  will  arise  in  the  appendix  from 
altered  conditions  due  to  operations  in  its  immediate  neighborhood,  but  in 
women  there  is  a  possibility,  although  a  remote  one.  that  the  appendix  may  be- 
come adherent  to  the  fresh  scar  resulting  from  operations  on  the  uterus  or  the 
right  ovary.  In  my  Operative  Gynecology,  published  in  1  *!>.">  vol.  _'.  p.  ~>s:  . 
I  said:  "The  vermiform  appendix  may  become  involved  in  post-operative 
adhesions  attaching  it  to  the  pedicle  left  in  the  pelvis,  and  causing  severe  pain 
in  the  right  iliac  fossa,  with  attacks  simulating  appendicitis.  I  operated  on  a 
patient  of  this  kind,  whose  right  ovary  had  been  removed  three  years  before 
by  H.  Robb;  I  removed  an  inflamed  left  ovary  and  the  uterus  tope! her  with 
the  appendix,  which  hung  over  into  the  pelvis  and  was  firmly  adherent  at  its 
end  to  the  pedicle  on  the  right  side."  Two  other  cases  of  this  kind  have  come 
to  my  own  personal  knowledge,  and  I  have  collected  six  more  reported  in  period- 
icals, or  sent  me  in  personal  communications.     I  cite  all  these  here  categorically. 


720 


APPENDICITIS    AND    CYXF.COI.OGICAL    AFFECTIONS. 


in  order  to   emphasize    the    necessity  of  guarding   against  a    rare   hut    possible 
contingency. 

1.  San.  No.  673,  Jan.  24.  1S90.  Miss  P..  twenty-five  years  old.  Both  ovaries 
had  lieen  removed  one  year  previously  on  account  of  painful  menstruation,  with- 
out relief.  On  opening  the  abdomen,  1  found  parts  of  both  ovaries  remaining,  and 
the  vermiform  appendix  was  adherent  to  the  remaining  tubal  and  ovarian  tissue  on 
the  right  side.      The  appendix  was  removed  as  well  as  the  diseased  tissues,  and  these 


Adhes.  due  to 

Suspension  of 

the  Uterus 


/ 


Fig.  3fi0. — Finney's  Case  of  Long   Appendix  Adherent  »v  its  Tip  to  Suspensory  Ligament  Attaching 

Uterus  to  Anterior  Abdominal  Wall. 
Case  of  myomectomy  and  suspension  by  author;  subsequent  operation  by  Finney  for  the  appenuical  complica- 
tion.     M.  O.  G-,  age  forty-two.     Jan.,  1902.     Recovery. 

measures  were  followed  by  a  good  recovery.     There  had  been  no  symptoms  of  appen- 
dicitis in  the  interval  between  the  two  operations. 

2.  J.  H.  H.,  Gyn.  No.  756G,  Feb.,  1900.  Miss  F.,  forty  years  old,  had  suffered 
from  pelvic  pain  and  irregular  menstruation  for  fourteen  years.  Ten  years  pre- 
viously a  conservative  operation  had  been  done  by  T.  A.  Emmet,  after  which  she 
was  somewhat  improved.  On  operation  I  found  the  uterus  in  retro-position,  with 
a  pedunculate  myoma,  three  times  its  size,  attached  to  the  fundus.  The  suspen- 
sory ligament  from  the  former  operation  had  stretched  to  about  10  cm.  in  length, 
but  both  tubes  and  ovaries  were  free  from  disease.     The  appendix  was  free  and 


REMOVAL    OF    APPENDIX    AS    A    PROPHYLACTIC    MEASURE.  721 

normal,  and  measured  8  cm.  in  length.  The  myoma  was  excised  and  its  stump 
sutured  with  catgut.  Two  small  subperitoneal  myomata  were  also  excised,  and  the 
suspensory  ligament  was  shortened.  The  abdominal  wound  was  closed  in  the  usual 
manner  with  catgut.  Uninterrupted  recovery  followed.  In  January,  1902,  how- 
ever, the  patient  was  readmitted  to  the  hospital,  just  after  a  third  attack  of  appen- 
dicitis, the  first  of  which  occurred  in  Egypt  six  months  after  the  gynecological 
operation  described.  At  a  second  operation,  performed  by  J.  M.  T.  Finney,  the 
appendix  was  found  with  some  difficulty,  its  tip  being  firmly  adherent  to  the  scar 
in  the  body  of  the  uterus  (see  Fig.  360).  The  uterus  was  normal,  but  the  right  tube 
and  ovary  were  bound  down  by  adhesions.  The  appendix  was  removed,  and  the 
small  granular  spot  to  which  it  had  adhered,  touched  with  pure  carbolic  acid,  and 
turned  in  with  several  mattress  sutures.     An  uninterrupted  recovery  followed. 

3.  H.  McGuire  (Trans.  Med.  Soc.  Va.,  1895).  A  married  woman,  twenty- 
four  years  old,  had  had  her  uterine  tubes  and  ovaries,  which  were  extensively  dis- 
eased, removed  by  Mc(iuire  two  years  before.  Eighteen  months  after  this  opera- 
tion the  patient  had  her  first  attack  of  appendicitis,  which  was  followed  by  several 
other  severe  attacks.  On  opening  the  abdomen,  the  appendix  was  found  attached 
to  the  stump  of  the  right  ovary,  sharply  bent  upon  itself,  and  flexed.  It  was 
easily  separated  and  brought  forward  for  inspection,  when  it  was  found  congested 
and  swollen.  After  removal,  it  proved  to  contain  several  hard  fecal  masses. 
The  patient  made  an  excellent  recovery. 

4.  Ibid.  A  married  woman,  forty-five  years  old,  had  had  both  ovaries  removed 
two  years  and  a  half  before.  Two  years  after  the  operation  she  had  her  first  attack, 
of  appendicitis,  after  which  other  attacks  recurred  at  intervals  of  a  few  weeks,  increas- 
ing in  severity.  At  the  time  of  the  second  operation,  there  was  great  pain,  fever, 
and  swelling  of  the  whole  flank,  but  no  mass.  On  opening  the  abdomen  the  appen- 
dix was  found  greatly  elongated,  swollen,  and  congested;  it  was  firmly  adherent 
to  the  stump  of  the  right  ovary,  from  which  it  was  peeled  loose  with  some  difficulty 
and  removed.  The  mucous  membrane  showed  ulcerative  changes  and  there  was  a 
mueo-purulent  secretion.     Recovery. 

5.  J.  Price,  1903.  (Personal  communication.)  In  this  case  hysterectomy  had 
been  performed  by  the  suprapubic  method.  A  few  years  later  the  patient  returned 
with  symptoms  suggesting  adhesions.  On  opening  the  abdomen,  the  appendix, 
which  was  thickened  and  diseased,  was  found  strongly  adherent  to  the  stump  of  the 
uterus. 

6.  Mayo  Robson,  1903.  (Personal  communication.)  The  patient,  a  middle- 
aged  woman,  had  had  an  abdominal  hysterectomy  performed  by  a  well-known 
surgeon  twenty  years  before  on  account  of  severe  pain  in  the  right  side.  At  the 
operation  the  surgeon  had  noticed  some  adhesions,  but  the  appendix  was  not  sus- 
pected, and  was  not  sought  for.  The  patient  made  a  good  recovery  from  the  opera- 
tion, but  never  completely  lost  the  pain  on  the  right  side  of  the  abdomen,  which 
became  more  troublesome  in  later  years.  When  seen  by  Robson,  she  presented 
all  the  symptoms  of  chronic  appendicitis,  for  which  he  operated.  The  appendix 
was  found  surrounded  by  firm  adhesions,  and  fixed  to  the  pedicle  on  the  right  side 
of  the  uterine  stump.  The  distal  end  of  the  appendix  was  obliterated,  but  the 
proximal   end    was   inflamed,  and   evidently  causing    trouble.     The  appendix  was 

removed,  after  which  the  patient  made  a  good  recovery  and  was  much  relieved. 
46 


722  APPENDICITIS  AND  GYNECOLOGICAL   AFFECTIONS. 

7. -Hid  S.  G.  R.  Fowler.  (Brooklyn  Med.  Jour.,  April,  1897.)  The  resemblance 
between  these  two  cases  in  their  histories  and  sequels  is  so  great  that  they  are  com- 
bined by  Fowler  for  the  sake  of  brevity.  The  patients  were  both  young  women, 
suffering  from  pyosalpinx,  who  were  operated  upon  by  double  oophorectomy  and 
salpingectomy  at  the  Methodist  Hospital.  In  both,  the  difficulties  of  removal 
of  the  adnexa  were  such  as  to  leave  more  or  less  exposed,  raw  serous  surfaces,  and 
in  both,  gauze  tamponing  and  drainage  were  necessary.  Both  left  the  hospital 
relieved,  to  return  within  six  months  complaining  of  symptoms  referable  to  the 
region  of  the  appendix.  On  re-opening  the  abdomen,  the  appendix  was  discovered, 
in  both  cases,  bound  by  adhesions  to  the  stump  at  the  site  of  the  amputated  right 
tube  and  ovary.  The  appendix  and  its  mesentery  in  each  case  had  been  subjected 
to  considerable  tension,  and  upon  examination  showed  indubitable  evidences  of 
chronic  inflammation  from  vascular  disturbances. 

In  speaking  of  these  cases  Fowler  remarks:  "This  experience  opens  up  a 
new  field  of  inquiry  as  to  the  causes  of  painful  stump  and  abdominal  symptom? 
sometimes  observed  to  follow  operations  upon  the  adnexa.  liver  since  the 
occurrence  of  these  two  cases,  I  have  made  it  a  rule  to  perform  typical  excision 
of  the  appendix  when  the  latter  is  intraperitoneally  situated,  in  every  case  in 
which  the  abdomen  is  opened  for  any  operative  structures  within  the  reach  of  this 
mischievous  and  useless  organ.'' 

Judging  from  the  evidence  just  collected,  it  seems  likely  that  adherence  of 
the  appendix  to  the  scar  of  a  previous  operation  stands  in  etiologic  relation  to  a 
post-operative  appendicitis  much  more  frequently  than  has  hitherto  been  sup- 
posed. Further  data  on  the  subject,  therefore,  are  to  be  desired.  These  can 
only  be  obtained  by  operators  for  appendicitis,  whether  they  are  gynecologists 
or  general  surgeons,  publishing  all  cases  in  which  the  appendix  is  found  adherent, 
to  a  scar  at  the  site  of  a  previous  operation.  The  value  of  such  statistics  will, 
of  course,  be  much  enhanced  if  it  can  be  shown  by  reference  to  a  previous  record 
that  the  appendix  was  normal  at  the  time  of  the  first  operation,  as  was  possible 
in  Case  .">;  we  have  here  also  an  additional  reason  for  not  neglecting  the  oppor- 
tunity to  examine  the  appendix  whenever  an  occasion  is  afforded  by  abdominal 
section,  as  well  as  its  removal  when  preternaturally  long,  or  lying  within  reach 
of  a  denuded  surface  in  the  peritoneum. 

In  order  to  avoid  just  such  accidents  as  the  adhesion  of  the  appendix  or  of 
any  other  intact  structure  to  the  raw  surface  in  the  pedicle,  Condamtn  of  Lyons, 
following  the  distinguished  Laroyenne,  has  urged  the  careful  covering  in  of 
all  raw  surfaces  created  by  surgical  operations  in  the  peritoneal  cavity.  He 
dignifies  this  important  principle  by  the  name  of  "  peritonisation"  (Lyon  med., 
1894,  p.  567).  McGuiRE,  in  the  article  referred  to  (lor.  tit.),  makes  the  important 
suggestion  that  whenever  the  right  ovary  is  removed,  the  raw  stump  should 
be  protected  by  covering  it  with  peritoneum  and  burying  it  out  of  sight.  H. 
Kreutzman  of  San  Francisco,  in  discussing  the  treatment  of  the  pedicle  in  ovar- 
iotomy and  salpingo-oophorectomy,  recommends  freeing  a  serous  cuff  from  the 


INCISIONS   Foil    REMOVAL   OF   APPENDIX.  723 

vessels  before  ligating  them,  and  after  the  ligation,  delicately  sewing  together 
the  serous  surfaces  so  as  to  cover  the  stump  completely  (Amer.  Jour.  Obst., 
1896,  p.  830).  The  same  plan  has  also  been  advocated  by  Watkins  of  Chicago. 
The  necessity  of  protective  measures  is  shown  by  the  cases  just  cited,  in  which 
the  adherence  of  the  appendix  to  a  raw  surface  after  the  removal  of  the  right 
ovary  was  the  exciting  cause  of  an  attack  of  appendicitis. 

Incisions  for  Removal  of  the  Appendix. — T  he  median  i  n  c  i  s  i  o  n  is 
best  in  cases  where  the  abdominal  walls  have  been  greatly  stretched  by  a  pelvic 
tumor,  or  by  repeated  pregnancies,  for  then  the  right  side  of  the  incision  is  easily 
drawn  over,  and  the  right  iliac  fossa  fully  and  easily  explored  (see  Chap.  XXIV, 
Fig.  240).  If  the  incision  is  not  more  than  two  and  a  half  inches  in  length,  it  is 
difficult  to  reach  the  appendix,  but  this  is  easily  accomplished  through  an  incision 
three  and  a  half  to  four  inches  long,  extending  not  less  than  three-quarters  or 
two-thirds  of  the  way  up  to  the  umbilicus.  The  incision  having  been  made,  the 
right  side  is  forcibly  retracted  toward  the  cecum,  which,  at  the  same  time, 
is  drawn  toward  the  opening.  If  the  cecum  has  a  short  mesentery,  and  the 
abdominal  walls  are  rigid,  it  may  be  necessary  to  make  another  separate  incision 
over  the  appendix  in  order  to  remove  it.  This  is  easily  done  by  introducing  the 
four  fingers  of  the  left  hand  into  the  abdomen  and  pushing  up  the  abdominal 
wall,  at  the  same  time  cutting  down  on  muscles  which  can  then  be  pulled  apart 
after  McBurney's  method  (see  Chap.  XXIV,  p.  533).  The  peritoneum  is  then 
opened,  the  appendix  picked  up  by  the  hand  inside  the  abdomen  and  pushed 
through  the  second  small  incision.  To  operate  in  this  manner  successfully  it  is 
always  necessary  to  have  the  patient  on  a  level  table,  as  Trendelenburg's  position 
causes  the  appendix  to  gravitate  up  toward  the  diaphragm,  and  it  cannot  be 
brought  down  without  dangerous  traction. 

Semilunar  Incision  . — In  cases  where  coincidence  of  appendicitis 
and  pelvic  disease  is  suspected  before  operation,  or  where  the  diagnosis  is 
doubtful  between  right-sided  pelvic  inflammation  or  extrauterine  pregnancy  and 
appendicitis,  the  best  incision  is  in  the  semilunar  line,  directly  over  the  right  side 
of  the  pelvis  and  close  to  the  root  of  the  appendix. 

Lateral  Incision  . — If,  after  opening  the  abdomen  in  the  median 
line  for  pelvic  disease,  an  abscess  is  found  in  association  with  the  appendix, 
it  is  best  to  open  the  sac  extra-peritoneally,  using  the  median  incision  as  a  guide. 
The  steps  in  the  operation  are  as  follows:  The  operator,  if  right-handed,  step- 
to  the  left  of  the  patient,  and  introduces  four  fingers  of  the  left  hand  into  the 
abdomen  in  such  a  manner  as  to  grasp  the  abdominal  wall  between  the  thumb 
and  fingers,  the  tips  of  the  fingers  resting  upon  the  point  of  contact  of  the  abscess 
with  the  abdominal  wall.  The  incision  is  then  rapidly  made  to  the  outside  of 
this  point  through  the  skin  and  muscles  and  then  cautiously  prolonged  into 
the  abscess;  if  there  is  any  uncertainty  as  to  its  exact  location,  the  blunt  end  of 
a  pair  of  artery  forceps  may  be  pushed  into  the  tissues,  after  incising  the  muscles, 
without  danger,  care  being  always  taken  to  avoid  opening  the  peritoneal  cavity 


Fio.  361> — The  Upper  Figure  show;*  Extensive  Involvement  of  Appendix  in  Tit  bo-ovarian  Abscess 
oi  i  be  Right  Side.  Widespread  Adhesions  to  Uterus  and  Pelvic  Walls.  The  Method  of  Removal 
i<  shown  in  Upper  and  Lower  Figuri  9 

V  the  meso-appendix  i~  tied  off  ami  the  appendix  detached  at  it--  base  and  grasped  as  shown  in  lower  figure, 
when  the  ovarian  vessels  are  exposed  and  tied  at  B.  Lastly  as  appendix,  uterine  tube,  and  ovary  are  lifted  out 
of  their  bed  of  adhesions,  the  tube  is  exsected  from  the  uterine  cornu  and  the  vessels  controlled  at  C. 

724 


METHODS    OF    REMOVING    APPENDIX. 


725 


by  the  fingers  inside  the  abdomen,  all  contamination  being  thus  limited  to 
the  hand  used  outside.  After  opening,  evacuating,  and  drying  out  the  abscess, 
and  putting  in  the  drain,  the  gloves  can  be  changed,  and  the  closure  of  the  median 
incision  proceeded  with.  If  any  intra-pelvic  operation  has  to  be  performed,  it 
had  best  be  done  before  opening  the  abscess  in  the  appendix. 

Removal  of  the  Appendix. — If  there  is  no  suppuration,  it  is  a  matter  of 
indifference  whether  the  appendix  or  the  pelvic  disease  is  first  treated,  but, 
generally  speaking,  it  is  best  to  do  the  pelvic  work  first,  and  that  on  the  appendix 
last,  so  as  to  close  the  opening  into  the  cecum  at  once.     If  there  is  suppuration 


leo-cecal  fold 


rd-ligt. 


Fig.  362. — Shows  the  Method  of  Removing  an   Adherent  Appendico-Tcbo-ovarian   Mass  in  Reverse 

Ohder,  Following  the  Arrows,   1  to  7. 


in  either  the  pelvis  or  the  appendix,  the  clean  operation  should  be  done  first. 
If  both  are  infected,  it  is  best  to  do  the  easier  first,  taking  put  the  appendix  at 
once  by  preference,  as  this  must  be  removed,  while  the  suppuration  in  the  pelvis 
can  be  quickly  drained  by  the  vaginal  vault. 

W h  c  n  the  Appendix  is  Adherent  to  the  O  v a  r  y 
and  Tube. — After  widespread  pelvic  peritonitis,  it  may  be  without  the 
presence  of  infective  organisms,  the  ovaries  are  often  adherent  and  attached 
to  the  pelvic  walls,  while  the  sigmoid  flexure,  together  with  the  appendix, 
is  bound  down  or  covered  in  by  adhesions.     If  the  adhesion  is  a  light  one,  it 


726 


APPENDICITIS   AND   GYNECOLOGICAL   AFFECTIONS. 


may  be  simply  detached,  and  the  pelvic  organs  treated  separately  to  the 
appendix,  as  their  condition  may  require.  If  the  adhesion  is  firm  and  inti- 
mate, one  of  two  plans  may  be  followed. 

1.  The  base  of  the  appendix  is  clamped  first  and  the  appendix  severed; 


Fig.  363. — H.  A.  Kei.ly.     Tubo-ovahian  Abscess.     PERX-APPENDicrns. 
Appendix  adherent  from  root  to  tip.  the  distal  portion  following  the  dotted  line  lies  upon  the  pelvic  floor 
under  tubo-ovarian  abscess.     Douglas'  pouch  is  obliterated.      E.  L..  colored,  age  eighteen.     Autopsy,  June  12, 
1899. 


t lie  ovarian  vessels  are  then  exposed  and  tied;  and,  lastly,  the  tube  is  exsected 
from  the  uterine  cornu  and  the  vessels  controlled  Csee  Fig.  361). 

2.  The  tube  or  the  tubo-ovarian  mass  is  first  detached,  beginning  at  the 
uterine  cornu.  and  enucleation  conducted  in  a  direction  the  reverse  of  that  just 
described  according  to  the  direction  indicated  by  the  arrows  in  the  figure,  the 
base  of  the  appendix  being  finally  clamped  and  severed  (see  Fig.  362). 

When  the  Uterine  Tube  and  the  Ovary  Coalesce  with  the  Appendix  to  form 


METHODS    OF    REMOVING    APPENDIX.  lit 

an  Abscess  on  the  Pelvic  Floor  (see  Fig.  363). — Under  these  circumstances 
extreme  caution  is  necessary  in  order  not  to  distribute  the  contents  of  the  abscess 
over  the  peritoneal  cavity.  In  the  case  of  a  large  abscess  with  a  patient  in  bad 
condition,  I  prefer  to  make  simply  a  vaginal  incision,  and  secure  good  drainage, 
leaving  the  appendix  to  be  removed,  if  possible,  at  a  later  date.  If  the  abscess 
is  small  and  situated  down  in  the  pelvis,  all  the  surrounding  parts  of  the  peri- 
toneum must  be  walled  off  with  gauze  and  completely  protected  from  contamina- 
tion upon  the  escape  of  the  pus.     The  appendix  should  then  be  detached  from 


Fig.  364. — H.  A.  Kelly.    The  Distal  Portion  of  the  Appendix  Adherent  to  the  Broad  Ligament  in  Case 
of  Large  Multilocular  Ovarian  Cyst.    H.  F.,  age  forty-eight.    June  4,  1902.    Recovery.    (Natural  size.) 


the  cecum,  and  its  mesentery,  together  with  the  ovarian  vessels,  tied  off.  The 
uterine  vessels  should  also  be  tied  at  the  uterine  cornu.  As  much  of  the  pus  as 
possible  should  be  removed  with  an  aspirator.  Then  the  surgeon  must  make  a 
cautious  effort  to  peel  out  the  whole  mass,  carefully  working  his  fingers  down 
underneath  it  in  the  posterior  pelvis.  Gauze  or  sponges  should  be  freely  used 
to  take  up  any  escaping  fluid.  If  when  the  mass  comes  away  it  leaves  any  por- 
tion of  its  infected  wall  clinging  to  the  pelvic  wall  or  floor,  the  latter  should  be 
scraped  with  a  knife-blade  or  a  curette,  and  then  freely  touched  with  pure  carbolic 
acid,  followed  by  alcohol,  after  which  the  whole  area  should  be  covered  with  a 


728 


APPENDICITIS   AND   GYNECOLOGICAL   AFFECTIONS. 


loose  handful  of  washed-out  iodoform  gauze,  draining  either  al  the  abdominal 
wound,  or  through  a  large  opening  at  the  back  of  the  cervix  into  the  vagina. 

When  the  Appendix  is  Strongly  Ad  lie  rent  to  a 
Tumor  of  the  Uterus  or  Ovary  (see  Fig.  364). — Under  these 
circumstances  the   best  plan  of  enucleation  is   to  detach   the  appendix   from 


FlG.  365.-  II.  A.   Kki.ly.     Appendix  Adherent  to  Uterine  Tthe  and  Ovary  in  the  Midst  of  Extensive 

Adhesions. 
The  fetus  shown  on  left  was  found  buried  apparently  in  substance  of  ovary.     A.  W.,  age  thirty.     May  31,  1902. 

Recovery.      (Natural  size.) 


the  cecum,  and  close  the  opening  at  once  if  possible.     The  tumor  should  then 
be  removed  with  the  appendix  attached  to  it. 

When  Appendicitis  is  Complicated  with  Ext  r  a  - 
uterine  Pregnancy  . — This  condition  offers  no  difficulties  not  dealt 
with  in  the  preceding  sections.  The  appendix  should  be  removed  either  with  the 
mass  or  separately,  as  the  occasion  requires  (see  Fig.  365). 


CHAPTER   XXX. 

RELATIONS  OF  APPENDICITIS  TO  PREGNANCY,  LABOR,  AND  THE 

PUERPERIUM. 

GENERAL  CONSIDERATIONS. 

The  relation  of  appendicitis  to  pregnane}-,  labor,  and  the  puerperium  de- 
mands especial  consideration  for  several  important  reasons.  The  extreme  grav- 
ity of  the  complications  which  may  arise,  involving  the  welfare  of  both  mother 
and  child,  as  well  as  the  diagnostic  difficulties,  and  the  risk  to  the  child  in- 
volved in  operation,  combine  to  render  this  one  of  the  most  difficult  questions 
for  the  obstetrician  and  for  the  surgeon.  Although  there  are  fairly  numerous 
references  in  the  literature  to  the  occurrence  of  appendicitis  during  pregnancy, 
the  cases  are  still  too  few  to  warrant  any  positive  conclusions  regarding  the 
relative  frequency  of  the  complication ;  and  as,  unfortunately,  only  severe  cases, 
in  general,  are  reported,  it  is  impossible  to  form  a  definite  opinion  concerning 
the  prognosis,  as  regards  either  the  mother  or  the  child.  In  the  early  literature 
only  a  few  isolated  cases  appeared.  A  case  described  by  Stumpf  in  1836,  as 
one  of  rupture  of  the  cecum  in  a  pregnant  woman,  was  probably  an  early  instance 
of  perforative  appendicitis;  but  the  first  case  clearly  recognized  as  such,  ami 
made  the  occasion  of  operation,  was  that  of  Hancock  (Lancet,  1848,  vol.  2, 
p.  381),  who  opened  a  perityphlitic  abscess  on  the  tenth  day  after  a  premature 
delivery.  The  patient  stated  that  she  had  observed  a  swelling  in  the  right  side 
of  the  abdomen  before  her  pregnancy,  but  previous  to  her  confinement  it  had 
not  caused  her  any  uneasiness.  Upon  opening  the  abscess  a  quantity  of  turbid 
serum  with  shreds  of  fibrin  and  false  membrane  passed  out.  The  patient  improved 
immediately,  but  the  wound  did  not  heal,  becoming  inflamed  and  painful,  until  at 
the  end  of  a  fortnight  two  fecal  concretions  escaped,  after  which  recovery  soon  fol- 
lowed (see  Chap.  Ill,  p.  48).  Abrahams  (Amer.  Jour.  Obst.,  1897,  vol.  35)  col- 
lected and  analyzed  15  cases,  which  were  all  which  had  been  reported  at  that  time. 

It  is  to  be  expected  that  appendicitis  should  frequently  develop  during 
pregnancy,  because  the  early  child-bearing  age  corresponds  with  the  time 
when  the  disease  is  most  frequent.  The  apparent  rarity  of  the  coexistence 
of  the  two  conditions  is  probably  to  be  explained  by  failure  to  recognize 
the  mild  forms  of  appendicitis,  the  symptoms  doubtless  being  often  attrib- 
uted to  disturbances  due  to  the  pregnancy;  many  of  the  more  severe  cases 
are  mistaken  for  puerperal  sepsis.  It  is  not,  however,  necessary  to  assume 
a  direct  etiologic  relationship   to   account    for   the   occurrence   of    appendic- 

729 


730  RELATIONS   OF   APPENDICITIS  TO   PREGNANCY   AND   I.AHOR. 

itis  during  pregnancy,  and  probably  in  the  majority  of  cases  the  coin- 
cidence is  purely  accidental.  Frankel  (Samml.  klin.  Vort.,  1898,  No.  229, 
]>.  133.")),  opposing  the  view  of  Hlawacek  I  Mount,  f.  Geb.  u.  Gyn.,  Bd.  6,  ]).  327) 
and  others,  who  hold  that  pregnancy  is  an  important  factor  in  the  causation  of 
appendicitis,  considers  that  the  appendix  is  subject  to  no  different  conditions 
in  pregnancy  than  at  other  times.  "An  organ  so  variable  in  its  size,  its  form 
and  position,  and  normally  so  freely  movable,  can  easily  become  adapted  to 
the  varying  condition  of  pressure  in  the  abdomen."  It  is  probable,  however, 
that  in  some  instances  pregnancy  and  labor  have  an  indirect  influence  in  exciting 
the  inflammatory  attack,  especially  when  the  appendix  is  already  prepared  by 
preexisting  disease.  The  obstinate  constipation  which  is  so  common  during 
the  later  months  of  pregnancy  may  readily  provoke  an  active  process  in  a  latent 
appendicitis,  while  the  excessive  engorgement  of  the  pelvic  and  hemorrhoidal 
veins  very  possibly  affects  the  circulation  in  the  appendix.  I.r.  GENDHE  {Rev. 
prat,  d'obst.  et  de  paed.,  1897,  No.  10,  p.  200)  refers  to  a  case  of  Tuffier's  in  which 
three  successive  pregnancies  were  accompanied  with  appendiceal  attacks.  Re- 
section of  the  appendix,  which  contained  a  concretion,  resulted  in  cure.  Le 
GENDHE  also  calls  attention  to  the  fact  that  during  pregnancy,  as  well  as  in  the 
non-pregnant  state,  the  menstrual  molimen  may  cause  relapses  in  a  chronic 
appendicitis.  He  relates  the  case  of  a  young  woman  who  had  suffered  from 
repeated  attacks  of  appendicitis,  and  in  her  first  two  pregnancies  the  appendical 
attacks,  which  had  always  been  mild,  occurred  in  greatly  aggravated  form. 
An  attack  during  the  second  month  of  the  second  pregnancy  was  accom- 
panied by  symptoms  of  peritonitis.  The  illness  gradually  subsided,  but  two 
days  after  the  date  for  the  menstrual  period,  an  acute  exacerbation  took  place. 
Recovery  again  followed,  but  it  was  decided  to  operate  eight  days  before  the 
time  for  the  next  period.  The  appendix,  which  was  perforated  at  its  base, 
was  resected,  together  with  a  mass  of  inflammatory  exudate  and  an  enlarged 
gland.  A  smooth  recovery  followed,  and  the  pregnancy  continued  its  normal 
course. 

When  the  appendix,  as  a  result  of  antecedent  inflammatory  attacks,  has 
become  adherent  to  the  uterus,  or  to  the  ovary,  tube,  or  broad  ligament  (see 
Fig.  366),  the  alteration  in  the  anatomic  relations  and  the  traction  upon  the 
appendix  consequent  upon  the  pregnancy  involve  more  or  less  danger.  The 
strong  contractions  of  parturition  and  the  sudden  diminution  in  the  size  of  the 
uterus  when  it  has  become  empty,  have  a  more  harmful  effect  than  the  gradual 
growth  of  the  uterus  during  pregnancy.  The  most  dangerous  complication 
is  met  with  when  the  uterus  forms  part  of  the  wall  of  a  peri-appendical  ab- 
scess. With  the  expulsion  of  the  fetus  and  sudden  contraction  of  the  uterus, 
rupture  of  the  abscess,  according  to  Konig,  is  almost  inevitable.  A  good  ex- 
ample of  the  danger  of  this  complication  is  described  by  Mtjret  (Zeit.  f.  Gyn., 
X<>.  94,  p.  1359),  where  in  the  fifth  or  sixth  month  of  pregnancy,  a  typical  appen- 
dicitis developed,  but  soon  subsided  with  a  disappearance  of  all  symptoms.    The 


EFFECT   OF   APPENDICITIS   UPON    PREGNANCY. 


rai 


pregnancy  went  on  to  term,  and  a  normal  delivery  followed,  but  two  days  later 
the  patient  died  from  perforative  peritonitis.  Autopsy  showed  that  the  contrac- 
tion of  the  uterus  had  caused  rupture  of  an  abscess. 

Mayo  Robson  (personal  communication,  1903)  has  operated  on  two  cases  of 
suppurative  appendicitis,  developing  almost  immediately  after  accouchment. 
The  first  case  was  one  of  suppurative  peritonitis  arising  from  an  appendix  which 
perforated  the  day  after  delivery.  Operation  was  performed  on  the  third  day,  the 
appendix  being  removed,  the  pelvis  and  abdomen  cleaned  of  pus,  and  lavage  of 
the  peritoneum  performed.    The  patient  completely  recovered.     In  the  second 


Fig.   366.— H.  A.  Kelly. 


Appendix   Adherent  to   the   Pregnant   Rudimentary   Uterine   Horn. 
from   Behind.     (Gyn.  No.  5802,  May,   1902.) 


Seen 


case,  acute  appendicitis,  ending  in  abscess  formation,  developed  a  few  days  after 
confinement.  At  operation,  performed  ten  days  after  delivery,  it  was  found 
that  the  appendix,  which  was  perforated  and  necrotic,  had  become  fixed  to 
the  open  end  of  the  right  tube,  down  which  the  pus  was  creeping.  The  tube 
and  appendix  were  removed  together  and  the  patient  made  a  good  recovery. 

The  Effect  of  Appendicitis  upon  Pregnancy. — No  statistical  proof  can 
be  obtained  from  the  limited  number  of  observations  reported  regarding  the 
relative  frequency  with  which  the  death  of  the  child  results  when  pregnancy 
is  complicated  by  appendicitis,  yet  all  writers  are  agreed  as  to  the  extremely 


732  RELATIONS  OF   APPENDICITIS  TO   PREGNANCY   AND   LABOR. 

grave  prognosis  for  it  in  severe  cases.  In  mild  attacks  the  normal  course  of  the 
pregnancy  is  not  disturbed.  BoiJE  (Pollak,  loc.  cit.,  Chap.  XXIX)  cites  IS  eases 
from  Engstrom's  clinic,  mostly  of  a  mild  type,  in  all  of  which  the  pregnancy  pro- 
ceeded normally.  In  other  cases,  even  where  a  severe  inflammation  is  cut 
short  by  operation,  the  pregnancy  often  proceeds  normally.  D.  Lewis  {Med. 
Recorder,  Chicago,  1901,  p.  369)  has  successfully  operated  on  five  occasions 
during  early  pregnancy.  In  one  instance  a  large  abscess  was  incised  and  drained 
in  the  fourth  month  of  pregnane)- :  and  the  labor  proceeded  without  incident. 
( '  Stuickler  (Gloniger,  Amer.  Med..  Jan.  10,  1903)  operated,  in  the  fifth  month 
of  pregnancy,  for  acute  appendicitis  with  obstruction  due  to  adhesions.  Recovery 
was  uneventful,  and  a  living  child  was  born  at  term.  T.  K.  Hoi.mks  (Amer. 
Jour.  Surg,  and  Gyn..  St.  Louis,  Feb.,  1903)  reported  the  case  of  a  woman  four 
months  pregnant,  operated  on  for  gangrenous  appendicitis  with  general  peri- 
tonitis. Recovery  followed,  and  the  pregnancy  proceeded  to  term,  when  a 
healthy  child  was  delivered.  Similar  cases  have  been  reported  by  I'kxrose, 
McCosh  and  Hawkks,  and  many  others.  Generally,  however,  in  severe  cases 
abortion  ensues.  In  some  instances  the  fetus  dies  ;//  utero  from  genera!  toxemia 
or  septicemia,  and  is  then  expelled.  Cases  have  been  described  in  which  the  infec- 
tion of  the  fetus  and  placenta  was  demonstrated  bacteriologicaUy.  In  KRONIG'S 
case  (loc  cit..  Chap.  XXIXj  a  recently  dead  fetus  was  delivered  spontaneously 
five  days  after  incision  of  a  peri-appendical  abscess.  The  bacillus  coli  corn- 
ea unis  was  found  in  pure  culture  in  the  organs  of  the  fetus,  in  the  placenta,  and 
in  the  large  uterine  veins.  In  most  instances  uterine  contractions  are  primarily 
excited,  and  a  living  child  is  delivered,  which,  however,  often  soon  dies  on  ac- 
count of  non-viability  or  from  infection.  The  uterine  contractions  may  be  pro- 
voked by  direct  inflammatory  irritation  or  through  general  constitutional  disturb- 
ance, especially  high  fever.  In  many  cases  premature  delivery  occurs  early  in 
the  appendical  attack,  and  in  such  a  case  a  healthy  child  may  he  born,  but 
when  delivery  occurs  after  the  patient  has  become  profoundly  septic  or  when 
infection  of  the  uterus  has  taken  place,  the  prognosis  for  the  child's  life  is  less 
favorable. 

With  the  act  of  parturition,  whether  it  occurs  at  full  term  or  prematurely,  a 
dangerous  complication  is  added.  In  the  first  place,  as  already  explained,  there 
are  the  almost  inevitable  rupture  of  adhesions  and  the  probability  of  general  dis- 
tribution of  the  infection;  and  in  the  second  place,  there  is  the  danger  of  infec- 
tion of  the  uterus  with  the  virulent  appendical  organisms,  constituting  a  true 
puerperal  infection. 

Oppenheimeh  (quoted  from  Pollak)  relates  the  case  of  a  woman  who,  in 
the  seventh  month  of  her  pregnancy,  presented  symptoms  of  peritonitis.  On 
the  third  day  a  living  child  was  born.  Three  days  later,  a  large  mass  resembling 
a  tumor  of  the  kidney  had  developed,  while  necrotic  masses  were  removed  from 
the  uterus.  The  patient  died  without  operation,  and  the  postmortem  showed 
peritonitis   resulting  from  perforative  appendicitis  and  secondary  infection  of 


DIAGNOSIS.  733 

the  placental  site.     A  case  of  unusual  interest  described  by  A.  Mante  (Arch, 
gen.  de  mid.,  1903,  No.  25,  p.  1547)  is  as  follows: 

The  patient,  two  days  after  delivers-  of  a  living  child  at  term,  began  to  have 
fever  and  fetid  lochia.  On  admission,  on  the  ninth  day,  her  abdomen  was  distended 
and  she  was  evidently  septic.  Curettage  and  intrauterine  lavage  were  followed 
by  a  general  improvement,  but  very  soon  the  temperature  again  became  elevated, 
the  pulse  small  and  rapid,  and  there  were  chills.  A  vaginal  hysterectomy  was 
then  performed,  and  the  uterus  was  found  large  and  edematous,  but  it  only  contained 
some  fibrinous  clots,  the  inner  surface  being  a  pale  pink  color.  The  patient  died 
four  days  later,  and  at  the  autopsy  the  pelvis  was  found  covered  with  greenish- 
white  fetid  pus.  and  the  appendix,  the  tip  of  which  was  gangrenous  and  perforated, 
hung  down  into  the  pelvis  and  was  in  contact  with  the  broad  ligament.  It  was, 
however,  absolutely  free,  and  was  doubtless  the  primary  focus  of  the  infection. 
The  bacteria  found  in  the  appendix  were  the  same  as  those  obtained  from  the  uterus. 

While  abortion  is  often  followed  by  a  rapidly  fatal  termination,  this  un- 
favorable result  is  not  necessarily  occasioned  by  the  miscarriage,  which,  as 
pointed  out  by  Fraxkel,  is  only  one  step  in  the  development  of  the  disease, 
and  the  severe  general  or  local  infection  which  induces  the  abortion  also  causes 
the  death  of  the  mother.  Konig  believes  that  the  presence  of  exceptionally 
dense  adhesions  between  the  intestines  and  pelvic  organs  may  interfere  with 
the  normal  growth  of  the  uterus  and  so  predispose  to  abortion.  In  one  case 
observed  by  this  writer  the  patient  had  been  the  subject  of  several  miscarriages, 
and  at  operation  the  adhesions  found  between  the  appendix,  the  intestinal  coils, 
and  the  uterus  were  so  dense  that  they  could  be  severed  only  with  the  knife. 
These  adhesions  may  also  interfere  to  some  extent  with  the  normal  involution  of 
the  uterus.  In  Crutcher's  case  (cited  by  Abraham),  after  abortion  complicat- 
ing gangrenous  appendicitis,  it  was  necessary  to  curette  and  pack  the  uterus, 
which  at  autopsy  was  found  to  be  normal  except  for  the  appendical  adhesion. 
In  Munde's  and  Thomason's  cases  (ibid.)  manual  removal  of  the  placenta  was 
necessary. 

DIAGNOSIS. 

The  diagnosis  of  appendicitis  complicating  pregnancy  may  be  exceedingly 
difficult.  A  typical  attack,  beginning  with  sudden,  severe,  abdominal  pain, 
soon  becoming  localized  in  the  right  side  and  associated  with  localized  tender- 
ness, muscular  rigidity,  and  constitutional  disturbances,  is  generally  recognized 
without  difficulty;  but  if  the  pain  and  tenderness  are  not  definitely  localized, 
and  the  constitutional  symptoms  are  slight,  the  pains,  especially  in  a  prhnipara, 
may  be  mistaken  for  a  threatened  miscarriage ;  and  even  if  the  pain  is  accom- 
panied with  vomiting,  this  is  of  little  value  in  the  diagnosis,  because  it  may  also 
accompany  labor  pains.  Still  greater  confusion  is  found  when  the  actual  partur- 
ition is  complicated  with  appendicitis,  as  the  symptoms  of  the  latter  may  be 


734  RELATIONS   OP   APPENDICITIS  TO    PREGNANCY   AND   LABOR. 

completely  masked  by  the  former  or  may  be  attributed  to  it.  In  a  case  related 
by  Hlawacek  the  patient  had  a  chill  a  few  hours  after  the  onsei  of  labor-like 

pain-,  and  it  was  difficult  to  determine  whether  the  chill  was  caused  by  labor 
or  if  there  was  an  appendicitis.  Palpation  and  percussion  are  often  unsatisfac- 
tory in  the  later  months  of  pregnancy  on  account  of  the  distention  of  the  abdo- 
men l>y  the  pregnant  uterus.     It  is,  however,  sometimes  possible  to  detect  an 

area  of  localized  rigidity,  and  a  tumor,  very  rarely  the  thickened  appendix,  may 
lie  clearly  defined  as  separate  from  the  uterus.  Frankel  suggests,  as  an  aid  in 
differentiating  a  peri-appendical  exudate  from  the  uterus,  that  the  patient  be 
placed  on  her  leftside,  when  the  uterus  sinks  in  that  direction,  and  the  inflam- 
matory mass  is  more  easily  palpated.  The  presence  of  a  severe  infection  is 
readily  recognized  by  the  characteristic  constitutional  disturbances,  and  its 
source  may  usually  lie  determined  if  a  careful  description  of  the  onset  of  the 
attack  is  obtained,  and  especially  if  there  is  found  to  be  a  history  of  antecedent 
appendicitis.  Great  difficulty  in  arriving  at  a  diagnosis  is  also  experienced  when 
the  appendicitis  develops  a  few  days  after  delivery,  in  which  case  the  symptoms 
may  simulate  puerperal  infection,  or.  indeed,  may  be  accompanied  with  a 
secondary  infection  of  the  uterus,  as  in  the  case  of  Mante,  already  cited. 

In  the  early  months  of  pregnancy  the  differential  diagnosis  between  uterine 
pregnancy  complicated  with  appendicitis  and  ruptured  ectopic  gestation  maybe 
very  perplexing.  The  distinguishing  features  have  already  been  described  in 
Chap.  XXIX.  The  differential  diagnosis  of  appendicitis  from  other  conditions 
accompanying  pregnancy  especially  pyelitis  and  other  renal  diseases,  is  based 
upon  the  same  characteristic  features  as  it  is  in  the  non-pregnant  state  (see 
Chap.  XVIII). 


TREATMENT. 

The  operative  treatment  of  appendicitis  in  pregnancy  and  in  the  puerperium 
i-  a  matter  of  great  importance,  as,  owing  to  the  constant  changes  in  the  anatomic 
relations  of  the  viscera,  the  severer  forms  of  the  disease,  in  which  an  abscess 
is  evolved,  are  less  liable  to  be  checked  or  limited  in  their  extent.  Furthermore, 
the  danger  always  involves  two  lives,  and  the  happiness  of  an  entire  family. 

For  these  reasons,  and  because  of  the  well-recognized  clinical  severity  of 
any  attack  of  appendicitis  associated  with  suppuration  during  pregnancy,  prompt 
interference  i-  demanded  as  soon  as  a  diagnosis  is  clearly  made.  The  operator, 
in  urging  upon  the  patient  a  prompt  recourse  to  surgical  treatment,  however, 
must  lie  guarded  in  his  statement-;,  for  uumerous  cases  are  recorded  in  which 
the  patient  has  refused  the  operation,  and  yet  lias  recovered,  gone  on  to  term, 
and  been  delivered  of  a  living  child.  Herrgott  has  said,  that  for  women  in  the 
child-bearing  period  of  life  the  operation  for  a  recurring  appendicitis  is  more  than 
usually  urgent,  on  account  of  the  dangers  they  incur  should  an  attack  take 
place  during  a  pregnancy.     In  these  cases,  therefore,  the  interval  operation  is 


TREATMENT.  735 

in  a  special  sense  prophylactic,  saving  both  mother  and  child,  a  risk  which  has 
often  been  reckoned  as  having  a  mortality  as  high  as  50  per  cent. 

The  earlier  in  the  course  of  pregnancy  the  operation  is  done,  and  the  earlier 
in  the  course  of  the  disease,  the  better  for  the  patient.  In  these  cases  the  usually 
conservative  surgeons  of  Germany  take,  as  a  rule,  the  same  radical  stand  which 
is  taken  by  their  American  and  French  colleagues.  Fraxkel,  for  instance, 
says  that  "in  case  of  a  relapse  in  a  pregnancy,  the  operation  is  to  be  recom- 
mended even  while  the  clinical  symptoms  are  of  a  mild  nature,  especially  in  the 
earlier  months  of  the  pregnancy.  " 

In  performing  the  operation  it  is  best  to  use  a  McBurney's  incision,  enlarg- 
ing it,  if  necessary,  by  dividing  the  aponeurotic  and  the  muscular  fibres  in  order 
to  secure  the  freest  possible  drainage  when  there  is  suppuration.  It  is  important 
to  handle  the  tissues  as  little  as  possible  in  the  course  of  the  operation,  and, 
above  all,  to  avoid  exposure  and  all  manipulations  of,  or  traction  upon,  the 
uterus.  The  intestines  should  be  well  packed  off,  and  the  whole  procedure 
should  be  conducted  under  the  assumption  that  any  infection  is  far  more  likely  to 
spread  throughout  the  peritoneum  than  under  ordinary  circumstances. 

If  the  operation  is  a  timely  one,  and  has  been  conducted  with  gentleness 
and  without  trauma,  undue  prolongation,  or  shock,  the  pregnancy  may  ad- 
vance to  term  without  interruption.  If  a  widespread  peritonitis  is  found 
associated  with  pregnancy,  the  hopes  for  the  patient's  life  are  but  small.  In 
such  cases  the  most  liberal  drainage  should  lie  used;  if  tympany  is  excessive, 
a  small  intestinal  fistula  should  be  made,  and  the  pregnancy  terminated  by 
emptying  the  uterus  per  vaginam.  It  is  of  the  utmost  importance  that  the 
pelvis  should  also  be  perfectly  drained,  preferably  in  an  upward  direction  on 
account  of  the  risk  of  infecting  the  uterus. 

In  the  case  of  an  active  appendicitis  occurring  at  the  end  of  pregnancy  the 
pregnancy  may  be  terminated  by  an  accouchement  force,  as  recommended  and 
practised  by  Marx,  to  save  the  life  of  the  child,  and  the  abdomen  then  opened 
in  order  to  treat  the  appendicitis.  The  risk  of  the  two  operations,  however, 
associated  with  the  likelihood  of  distributing  an  infection  by  the  contractions 
and  changing  volume  of  the  uterus,  is  so  great  that  this  plan  should  be  adopted 
only  in  exceptional  cases.  When  there  is  reason  to  believe  that  pus  is  present 
or  that  an  abscess  has  formed,  it  is  wiser  to  open  and  drain  simply  and  let  the 
uterus  alone.  Such  cases  can  go  on  undisturbed  to  term,  with  apparently 
less  risk  than  if  the  uterus  is  emptied  at  once  in  order  to  anticipate  the  slow 
abortion  which  often  occurs,  but  upon  this  point  further  data  are  wanting. 

While  appendicitis  occurring  in  the  course  of  pregnancy  is  dangerous,  it  is 
still  more  dangerous,  and  prompt  interference  is  even  more  urgent,  in  appendic- 
itis arising  in  the  early  puerperium.  In  some  instances  these  cases  owe  their 
origin  to  the  recent  violent  changes  in  the  anatomic  relations  of  the  lower  abdom- 
inal viscera,  which  break  up  adhesions,  and  where  the  uterus  has  formed  part  of 
the  protecting  wall  of  an  abscess,  rupture  the  sac,  and  distribute  its  contents 


736  RELATIONS   OF   APPENDICITIS  TO    PREGNANCY   AND   LABOR. 

through  the  peritoneum.  This  la.st  group  of  cases  is  well-nigh  hopeless;  never- 
theless a  prompt  operation  should  be  performed,  and  liberal  drainage  instituted. 
If  the  appendicitis  comes  on  during  labor,  it  is  best  to  terminate  labor  first, 
and  then  make  sure  of  the  diagnosis  and  operate  on  the  appendicitis  (  LaBHARDT). 


CHAPTER  XXXI. 
NEOPLASMS. 

BENIGN  TUMORS.     MALIGNANT  TUMORS. 

Introductory. — The  number  of  cases  recorded  of  primary  tumors  in  the 
vermiform  appendix  is  small,  but  during  the  past  few  years,  since  the  operative 
treatment  of  right  iliac  disease  and  careful,  routine,  laboratory  examination  of 
the  removed  organ  have  become  general,  it  has  been  found  that  they  are  by  no 
means  so  rare  as  was  formerly  supposed.  The  few  instances  described  in  the 
older  literature  were  supposed  to  belong  to  the  carcinomata,  but  owing 
to  the  lack  of  microscopic  examinations  and  the  meagre  description  of  the  gross 
appearance,  there  is  just  doubt  in  many  of  these  cases  as  to  the  true  nature 
of  the  growth.  Since  1898  a  considerable  number  of  cases  of  malignant  neoplasms 
limited  to  the  appendix  have  been  carefully  described,  while  secondary  involve- 
ment of  the  organ  is  comparatively  common.  Benign  tumors,  however,  are 
still  fit  would  appear)  extremely  rare.  This  may  be  partly  owing  to  the  fact 
that  on  account  of  their  small  size  and  clinical  insignificance  they  have  not  been 
considered  worthy  of  special  attention.  The  tumors  originating  in  the  appen- 
dix may  be  classified  as  follows: 


Benign  Tumors : 


Polyp. 

Myoma.  ,  ~      . 

Fibroma.  Malignant  Tumors :  -1  ~ 

,  Sarcoma. 
Myxoma. 

Lipoma. 


In  addition  to  these  it  may  be  mentioned  that  Lafforgue  (These  de  Paris) 
mentions  two  instances  of  1  y  m  p  h  -  a  d  e  n  o  m  a  t  a  of  the  appendix;  and  in 
a  case  of  Hodgkin's  disease,  furnished  me  by  L.  Hektoex  of  Chicago,  the  appendix 
was  enormously  enlarged,  forming  a  sausage-shaped  tumor  12  by  2.5  cm.  Its 
walls  were  uniformly  thickened,  the  canal  almost  obliterated,  and  the  neighboring 
portion  of  the  cecum  contained  a  large  lymphomatosis  mass  which  projected 
into  the  bowel.  Microscopic  examination  revealed  the  usual  hyperplasia  of 
lymphoid  elements. 

BENIGN  TUMORS. 
Polypi. — Unlike  other  portions  of  the  intestinal  tract,  the  appendix  is  hut 
rarely  the  seat  of  these  formations,  and  so  far  as  I  can  discover  no  cases  have 
47  737 


738 


NEOPLASMS. 


been  mentioned  in  the  literature.  I  have  observed  four  instances,  one  of 
which  occurred  in  my  own  practice.  In  subacute  inflammation  the  mucous 
membrane  lining  the  appendix  is  often  thrown  up  into  polyp-like  folds,  which 
may  be  so  exuberant  as  to  form  a  distinct  tumor,  causing  considerable  distention 
of  the  canal,  and  at  first  sight  even  suggesting  a  new-growth.  Inspection 
of  the  sectioned  surface,  however,  shows  that  the  outgrowths  are  composed  of 

submucosa  and  mucosa,  and  differ  from  true  tumors  in  that  the  tissues  preserve 
their  normal  relations  to  one  another.  Histologically,  there  is  merely 
a  more  or  less  severe  inflammatory  process,  characterized  by  a  marked  increase 


Kolyp 


Fig.  'J67. — H.  A.  Kelly.     Polypoid  Mass  l:i)  Pito- 

JECTXNG  FROM  THE  CECAL  END  OF  THE  Al'IM  \I.1X. 

Kiwi.  No.  7272.) 
a',  Cut    surface    <>t    polyp;   b,  mucosa;   c,  submu- 
cosa; di  musculature. 


A.M. 


Fir..  368. — Oyiatt's  Cask  of  Polyp  in  the  Appen- 
dix, Removed  Six  Weeks  after  an  Attack  oh 
Appi  M'H'ITIS. 


in  the  number  and  size  of  the  blood-vessels,  associated  with  hyperplasia  of 
stroma  cells  and  leucocytic  infiltration.  A  good  example  of  this  condition  is 
illustrated  in  Fig.  3G7. 


J.  It.  II.,  Gyn.  No.  7272.  The  patient,  a  woman  thirty-two  years  old,  was 
operated  on  for  pelvic  inflammatory  disease.  There  was  a  tubo-ovarian  abscess 
on  the  left  side,  and  on  the  right,  the  appendix  was  adherent  to  the  inflamed  tube 
and  ovary.  There  was  no  history  of  appendicitis,  the  patient's  only  complaint 
being  of  a  profuse  vaginal  discharge.  The  appendix  was  short,  with  its  somewhat 
bulbous  extremity  buried  in  adhesions.  Its  base  was  densely  attached  to  an  area  of 
thickened  cecum  extending  about  2  cm.  on  all  sides.  The  bowel  was  extensively 
opened  by  amputation  of  the  appendix  with  the  entire  thickened  area  of  cecum. 
Projecting  from  the  orifice  of  the  appendix  was  the  curious  polypoid  mass  shown 
in  the  figure.     The  microscope  showed  merely  a  subacute  inflammation. 


MYXOMA,    MYOMA,    FIBROMA.  739 

Single  sessile,  or  pedunculated  polypi  are  also  the  product  of  an  inflamma- 
tory process.  They  may  be  composed  entirely  of  mucous  membrane,  but  more 
often  they  have  a  stem  consisting  of  the  submucosa.  In  the  specimens  that 
I  have  seen,  the  glands  of  Lieberkiihn,  the  stroma,  and  the  lymph  nodes  were 
well  preserved  and,  excepting  for  slight  congestion  of  the  blood-vessels  and  leu- 
cocytic  infiltration,  the  tissue  was  normal.  The  specimen  shown  in  Fig.  368 
was  removed  at  operation  by  C.  W.  Oyiatt  of  Oshkosh,  Wis.  The  patient,  a 
boy  of  twelve,  had  suffered  from  a  severe  attack  of  appendicitis  six  weeks  pre- 
viously, and  at  the  time  of  his  admission  to  a  hospital  a  tender  mass  was  detected 
in  the  region  of  the  appendix.  On  opening  the  abdomen  a  perforation  was  found 
near  the  base  of  the  appendix  and  a  moderate-sized  fecal  concretion  lay  free  in 
an  abscess  cavity.  The  middle  portion  of  the  appendix  was  abruptly  distended, 
and  upon  being  opened  after  removal,  proved  to  contain  a  small  pedunculated 
tumor.  Under  the  microscope  this  was  found  to  consist  of  the  normal  elements 
of  the  mucous  membrane.  The  specimen  shown  in  Chap.  XII,  Fig.  17:!.  was 
removed  at  operation,  by  I.  R.  Trimble,  for  acute  appendicitis,  and  shows  prac- 
tically the  same  structure.  A  similar  specimen  was  sent  to  J.  C.  Bloodgood 
by  Carson  of  St.  Louis. 

Myxoma. — The  only  instance  of  myxoma  in  the  vermiform  appendix  that  I 
find  recorded  is  a  case  shown  by  Chdrton  to  the  Medical  and  Surgical  Society  of 
Leeds  (H.  Aboulker,  These  de  Paris,  1899).  The  patient,  a  young  woman,  twenty- 
two  years  old,  admitted  with  a  history  of  two  attacks  of  appendicitis,  complained  of 
being  unable  to  work  on  account  of  constant  pain  in  the  cecal  region.  The  appen- 
dix was  removed  by  Mayo  Robsox.  It  presented  a  thickened  extremity,  and  on 
being  opened  showed  a  sessile,  transparent  tumor,  the  size  of  a  small  haricot-bean, 
obstructing  the  lumen  to  within  3  cm.  of  the  tip,  which  was  slightly  distended 
with  mucus.  There  were  no  adhesions  nor  other  sign  of  peri-appendicitis. 
An  instance  has  also  come  under  my  own  observation  in  which  the  tumor 
was  attached  to  the  peritoneal  surface  of  the  appendix.  The  patient  was  a 
young  colored  girl,  upon  whom  an  exploratory  laparotomy  was  performed  for 
the  purpose  of  discovering  the  cause  of  severe  abdominal  pains  of  which  she 
complained.  Nothing  was  found  except  a  few  adhesions  between  the  liver  and 
the  anterior  abdominal  wall  and,  attached  to  the  middle  of  the  appendix,  which 
was  hypertrophied  and  obliterated,  but  free,  was  a  small,  firm,  transparent 
nodule,  1.5  by  1  by  0.8  cm.  in  size,  which,  on  microscopic  examination,  proved 
to  be  a  pure  myoxnia. 

Myoma  and  Fibroma. — Three  cases  of  myoma  of  the  appendix  have  been 
recorded,  two  by  A.  0.  J.  Kelly  and  one  by  Hayem.  In  the  two  cases  described 
by  Kelly  the  tumors  were  small,  about  5  mm.  in  diameter,  and  were  situated 
in  the  muscular  coat.  They  were  designated  fibro-myomata.  In  one  case 
(Kelly)  there  was  a  considerable  amount  of  calcareous  deposit.  In  all  three  cases 
there  was  an  associated  chronic  inflammation  of  the  appendix,  characterized  by 
hypertrophy  of  its  walls  and  arteriosclerosis.     The  case  of  probable  parasitic 


740 


XKOPLASMS. 


myoma  shown  in  Fig.  369  was  removed  from  a  woman  who  was  operated  on 
for  uterine  myoma.  The  iliac  tumor,  which  had  no  anatomic  connection  with 
the  uterine  growth,  was  situated  behind  a  peritoneal  fold  and  received  its  blood- 
supply  by  branches  from  the  superior  mesenteric  vessels.  A  similar  case  is 
described  by  Sonnenburg,  but  in  this  instance  the  appendix  was  not  found. 
Fibroma  limited  to  the  appendix  lias  not  been  reported,  but  in  this  connec- 
tion a  remarkable  tumor  of   the  kind,  which  chiefly  involved  the  appendix 


I  ii..   :i09. — T.  S.  Cullen'b  Care  ok  Parasitic  Myoma  Adherent  to  the  Appendix.     (Path.  No.  5754.) 

and  had  evidently  originated  in  the  mesentery  of  the  appendieo-eecal  region, 
was  observed  in  the  gynecological  department  of  the  Johns  Hopkins  Hospital. 
The  history  of  the  case  is  briefly  as  follows: 

M.  P.,  colored,  aired  thirty-three,  was  admitted  complaining  of  an  abdominal 

tnmor,  noticed  for  the  first  time  six  weeks  before.  At  that  time  the  tumor  was 
about  the  size  of  a  large  duck-egg  and  was  situated  low  down  on  the  left  side.  It 
increased  rapidly,  and  two  months  before  admission  she  was  told  by  her  physician 
that  the  tumor  was  the  size  of  two  fists.     There  was  no  pain,  and  the  patient  stated 


FIBROMA. 


741 


that  if  she  had  not  felt  the  hard  mass,  she  would  not  have  been  conscious  of  its  pres- 
ence. Defecation  was  normal;  her  appetite  and  digestion  good;  micturition  was 
somewhat  frequent.  On  examination  the  lower  abdomen  was  found  to  be  occupied 
by  a  large  tumor  somewhat  more  prominent  on  the  left  side.  There  was  consider- 
able bulging  in  both  flanks,  but  especially  in  the  right.  The  tumor  was  slightly 
movable  from  left  to  right,  more  movable  upward  and  downward.  The  mass  ex- 
tended up  to  and   was  lost  under  the  right  costal  margin.     Pelvic  examination 


Ileo-  colic 
ori/ice 


Gland. 


Glands 


Fig.  370.— H.  A.  Kelly. 


Fibroma  of  the  Appendix  and  Appendico-cecai.  Angle.     Anterior  Aspect  of 
Tumor.     (M.  P.,  age  thirty-three.     Jan.  22,  1900.) 


showed  that  the  uterus  was  small  and  pushed  into  retroposition  by  the  hard  tumor 
which  extended  down  into  the  true  pelvis.  The  diagnosis  was  tumor  of  the  right 
ovary.  On  operation,  a  median  incision  exposed  the  tumor  lying  between  the  layers 
of  the  mesentery  and  behind  the  peritoneum  of  the  iliac  fossa,  with  the  ileum  lying 
like  a  flat  cord  on  its  upper  surface,  to  the  length  of  10  cm.,  the  cecum  and  the 
ascending  colon  being  spread  over  it  to  the  same  extent.  The  appendix,  which 
was  IS  cm.  long,  disappeared  entirely  for  9cm.  of  its  length  into  the  substance  of  the 


742 


NIK  il'I. ASMS. 


tumor,  its  distal  half  being  free.  The  enlarged,  congested  ovarian  vessels  coursed  down 
over  the  surface  (see  Figs.  370  and  371).  A  free  incision  was  made  through  the 
peritoneum  on  the  convex  surface  of  the  tumor,  in  the  hope  of  enucleation  and 
of  avoiding  a  resection  of  the  bowel,  but  the  hemorrhage  was  so  free  that  this  plan 
had  to  lie  abandoned.  The  mesenteric  vessels  were  then  tied  off  and  the  bowel 
ligated  at   two  points,  one  above  and  one  below  the  tumor.     The  ovarian  vessels 


Fig.  371. — Fibroma.     Posterior  Aspect. 


•were  then  ligated  at  the  point  where  they  were  attached  to  the  under  surface  of  the 
tumor,  a  hydroureter  being  laid  bare  where  it  entered  the  tumor,  and  resected 
to  the  extent  of  5  cm.  of  its  length.  The  bowel  was  united  by  an  end-to- 
end  anastomosis  of  the  ileum  into  the  cecum,  and  the  ureter  was  similarly 
united.  The  latter  procedure  was  difficult  on  account  of  the  distended  condition 
of  the  proximal  end,  and  the  tension  arising  from  the  removal  of  5  cm.  of  its  length. 
Drains  were  placed  leading  down  to  the  site  of  each  of  the  anastomoses.      Conva- 


CARCINOMA.  743 

lescence  was  interrupted  by  the  development  of  a  ureteral  fistula  on  the  second 
day,  but  this  gradually  closed  and  the  patient  was  discharged,  well,  at  the  end 
of  seven  weeks.  Histologic  examination  showed  that  the  tumor  was 
a  typical  fibroma,  of  generally  uniform  appearance  but  edematous  in  places, 
and  slightly  infiltrated  with  plasma  and  lymphoid  cells.  The  vascularity  was 
moderate.  The  most  interesting  portion  of  the  tumor  was  that  where  parts  of  the 
intestine  were  involved.  The  cecum  and  ileum  were  flattened  from  before  backward; 
the  mucosa,  while  showing  the  signs  of  pressure,  was  practically  normal;  the 
muscular  coats  of  the  anterior  wall  were  normal,  but  the  longitudinal  layer  of  the 
posterior  wall  had  to  a  great  extent  been  replaced  by  tumor  cells.     The  appendix 


Fig.  372. — Fibroma  of  the  Appendix.     Section  from  the  Preceding  Case,  Magnified  Eight  Times,  Show- 
ing the  Appendix  Embedded  in  the  Tumor. 
The  canal  of  the  appendix  is  seen  to  be  pervious,  and  the  mucous  and  submucous  layers  practically  normal. 
The  muscular  coats  in  this  section  are  fairly  well  preserved  except  on  the  side  corresponding  to  the  mesenteric 
attachment. 

had  a  patent  lumen  throughout,  and  the  mucosa  was  well  preserved,  but  where  the 
organ  was  most  deeply  embedded  in  the  tumor,  the  muscular  coats  had  been  almost 
entirely  replaced  by  connective-tissue  fibres  (see  Fig.  372). 


MALIGNANT  TUMORS. 

Carcinoma. — The  older  writers  were  of  opinion  that  all  neoplasms  of  the  ap- 
pendix were  secondary,  and  it  was  not  until  Merlixg  in  1838  (Jour,  de  I'exper., 
1838)  described  a  case  of  primary  carcinoma  that  it  began  to  be  referred  to  in  litera- 
ture. The  second  case  was  reported  by  Prus  in  1865  (Crozet,  These  de  Paris),  and 
two  years  later  Rokitaxsky  described  4  cases  of  colloid  tumor  of  the  appendix 
(Med.  Jahrb.,  1867,  Bd.  3,  p.  3).    Ten  years  ago  the  total  number  of  cases  re- 


71  1  NEOPLASMS. 

ported  was  12,  and  only  one  of  these  was  described  histologically.  The  cases 
of  Maydl  (Ueber  Darmkrebs,  1883),  of  Leichtenstern  (Ziemssen,  Hand- 
buch,  1876),  :iinl  of  I. i:\ia.n  were  mentioned  in  autopsy  statistics  without  further 
comment ;  in  other  cases  the  description  left  some  doubt  as  to  the  nature  of  the 

disease  in  some  instances,  and  in  some,  again,  as  to  the  Organ  in  which  the  growth 
originated.  The  majority  of  the  early  cases  described  cannot,  therefore,  be 
accepted  as  genuine  instances  of  primary  carcinoma  of  the  appendix. 

1  hiring  the  past  ten  years,  as  stated  above,  the  Dumber  of  cases  reported  has 
been  greatly  augmented,  and.  in  most  instances,  the  tumors  have  been  carefully 
described.  A.  \Y.  Elting  in  I 903  reported  40  cases  of  carcinoma  of  the  appendix 
collected  from  literature  to  the  New  York  Stale  Medical  Society,  24  of  which 
were  undoubtedly  primary  (Traits.  N.  V.  Med.  Sue.,  1903,  p.  324).  Since  then 
three  cases  have  been  reported  by  Moschowitz  (Ana.  Surg.,  1893,  vol.  37,  p. 
891);  one  by  Norms  (Univer.  Perm.  Med.  Hull..  Nov.,  1903,  p.  .'!.">t);  one  by 
Weir  (N.  Y.  Med.  Rec,  May.  1903) ;  and  one  by  Burnam  (Johns  Hopkins  Bull., 
1904,  ]i.  136).  There  are  now  on  record  49  cases  of  carcinoma  of  the  appendix, 
including  2  designated  endothelioma.  Thirty  cases  are  described  microscopic- 
ally, and  appear  to  have  been  undoubted  instances  of  primary  tumor  of  the 
appendix,  and  it  is  possible  that  some  of  the  less  carefully  described  should 
really  be  included  in  this  category.  There  are  also  ">  instances  of  primary  sar- 
coma of  the  appendix.  Four  cases  of  malignant  disease  of  the  appendix,  hitherto 
unpublished,  may  be  added  to  this  number,  namely,  3  of  carcinoma  and  one  of 
sarcoma,  all  of  which  were  discovered  at  operation,  undertaken  for  the  relief  of 
chronic  appendicitis.     Brief  histories  of  these  cases  of  carcinoma  are  as  follows: 

1.  Thorndike.   Boston  City  Hospital.    Woman,  thirty  years  old,  with  a  history  of 

recurrent  appendicitis  extending  over  a  period  of  seven  years.  One  week  before 
admission  the  pain  became  very  severe  and  continuous.  ( >n  examination,  tenderness 
was  elicited  on  deep  palpation  over  the  right  iliac  fossa,  and  a  small,  cord-like  structure 
was  felt  close  to  the  ilium.  In  a  few  days  the  pain  and  tenderness  had  practically  dis- 
appeared, but  the  patient  desired  operation  to  prevent  further  trouble.  The  appendix 
was  found  very  much  thickened,  the  distal  portion  cystic,  and  the  base  much  indu- 
rated ;it  was  removed,  a  V-shaped  portion  of  the  cecum  being  taken  out  with  its  base. 
The  wound  in  the  cecum  was  closed  without  drainage.  The  patient  made  an  unin- 
terrupted recovery.  Histologic  examination  showed  that  the  prox- 
imal indurated  portion  of  the  appendix  was  the  seat  of  a  carcinoma  which  had 
infiltrated  all  the  coats  out  to  the  peritoneum.  The  growth  was  characterized  by 
the  formation  of  small  alveoli  lined  with  columnar  cells,  which  often  entirely  filled 
the   lumen. 

2.  Monks.  Boston  City  Hospital.  A  woman,  twenty-four  years  old,  was 
admitted  with  a  history  of  two  days'  illness  beginning  with  pain  in  the  epi- 
gastrium  which  soon  settled  in  the  lower  abdomen,  chiefly  on  the  right  side.  There 
was  no  vomiting  and  the  bowels  moved  daily  with  enemata.  Her  family  history 
was  good.     She  had  had  no  previous  attacks  of   the  kind,  but  had  been  troubled 


CARCINOMA.  745 

more  or  less  with  indigestion.  She  had  had  '"grip"  five  years  before.  On  admis- 
sion the  patient  appeared  nervous,  but  not  apparently  in  much  pain.  Her  general 
condition  was  good.  The  abdomen  was  natural-looking  and  soft;  palpation  elicited 
moderate  tenderness  to  the  left  and  below  the  umbilicus,  and  very  slight  muscular 
spasm  over  these  areas.  The  patient  was  kept  under  observation  for  several  days 
and  presented  no  new  symptoms,  although  the  pain  continued.  Operation  showed  that 
there  was  no  free  fluid  in  the  abdominal  cavity  and  the  serosa  was  normal  in  appear- 
ance. The  appendix  was  found  lying  in  the  iliac  fossa  near  the  head  of  the  cecum 
and  twisted  upon  itself.  The  tip  was  bulbous  and  was  enveloped  in  a  mass  of  chronic 
inflammatory  exudate,  from  which  it  was  separated  with  comparative  ease.  The 
appendix  was  extirpated  and  the  abdomen  closed,  with  the  exception  of  a  very 
small  drain,  removed  two  days  after  operation,  and  the  provisional  sutures,  which 
were  tied.  The  wound  united  by  first  intention  and  the  patient  made  an  unevent- 
ful recovery. 

Pathologic  report:  Gross :  Appendix  opened  lengthwise,  5  cm.  long, 
mesentery  adherent  with  some  fat.  Surface  reddened.  Mucous  membrane  grayish 
and  gelatinous.  Yellowish  nodule  0.6  cm.  in  diameter,  1.5  cm.  from  distal  end. 
Microscopic:  Slight  infiltration  of  muscularis  with  lymphoid  cells.  At  site  of  tumor 
the  mucosa  is  entirely  replaced  by  a  mass  composed  of  connective  tissue  surrounding 
collections  of  epithelial  cells.  Anatomic  Diagnosis :  Adeno-carcinoma.  Slight  chronic 
appendicitis. 

3.  J.  H.  H.,  Surg.  No.  9037.  A  colored  man,  aged  nineteen,  was  admitted 
with  a  history  of  recurring  abdominal  cramps,  but  never  any  characteristic  appen- 
dical  attacks.  Bowels  regular,  appetite  good.  The  family  history  was  negative. 
Ten  days  before  admission  he  was  seized  with  general  abdominal  pains,  but  con- 
tinued to  go  about  until  the  eighth  day,  when  the  pain  became  more  severe,  diarrhea 
set  in,  and  he  vomited  once.  There  was  no  abdominal  distention  nor  general  ten- 
derness. In  the  right  half  of  the  abdomen  the  abdominal  muscles  were  slightly 
rigid,  and  in  the  iliac  fossa  there  was  a  distinct  oblong  mass.  This  was  extremely 
painful,  and  light  palpation  over  the  tumor  elicited  active  muscle  spasm.  His  tem- 
perature was  101.8°  F. ;  his  pulse  110;  the  leucocytes  16.000.  Operation 
showed  the  tumor  mass  to  consist  chiefly  of  a  thickened,  adherent  omentum  which 
walled  off  a  small  abscess,  containing  fetid  pus,  from  the  general  peritoneal  cavity. 
The  appendix  was  densely  adherent  to  the  wall  of  the  abscess.  It  was  removed 
with  difficulty,  the  last  2  cm.  being  freed  only  by  stripping  off  the  outer  coat.  The 
abdomen  was  closed  with  a  small  drain.  Recovery  was  uneventful.  The  appen- 
dix was  8  cm.  long  and  markedly  thickened  (see  Fig.  273).  It  was  partly  surrounded 
with  adherent  omentum,  and  a  perforation  opened  into  the  adherent  mass.  About 
2  cm.  of  the  median  portion  of  the  appendix  was  much  more  dense  than  other  por- 
tions, and  on  section  this  area  was  found  to  be  the  seat  of  a  new-growth,  which  had 
obliterated  the  lumen  and  penetrated  to  the  peritoneal  layer.  A  small  perforation 
was  found  at  the  junction  of  the  tumor  with  the  distal  portion  of  the  appendix. 
The  cut  surface  of  the  tumor  was  sharply  differentiated  from  the  surrounding  tis- 
sue, and  consisted  of  dense,  whitish,  partly  granular,  partly  fibrillated,  tissue.  The 
mucous  surface  was  necrotic.  Histologic  examination  showed  that 
the  tumor  was  made  up  of  small  alveoli  closely  packed  with  small  polymorphous 
cells  having  a  scanty  protoplasm  and  sharply  stained  nuclei.     All  the  coats  were 


711) 


NEOPLASMS. 


seen  to  be  invaded,  bul  on  account  of  the  poor  preservation  of  the  specimen,  the 
relation  of  the  growth  to  the  mucosa  could  not  be  studied. 

Pathology.— As  regards  location  of  the  tumor,  its  growth  is 
indicated  in  2  I  cases.  Of  these,  S,  or  one-third,  were  situated  at  the  tip  of  the 
appendix,  and  .">  others  were  within  4  to  .">  cm.  of  the  tip.      In    EtOLLESTON's 


minute    perforatioa 


Fig.  373. — W.  S.  Halsted's  Case  of  Carcinoma  of  the  Appendix  Causing  Acute  Perforative  Appendicitis. 

(Surg.  Path.  No.  2599.) 


case  (Lancet,  1000,  vol.  2)  the  tumor  is  described  as  being  near  the  tip.  In 
5  instances  the  growth  was  situated  at  or  near  the  cecal  attachment  of  the  appen- 
dix, and  in  the  remaining  •">  cases  at  intermediate  points.  It  is  noteworthy  that 
in  more  than  half  the  cases  the  growth  was  located  at  or  near  the  distal  extrem- 
ity, and  in  only  5  instances  was  it  found  near  the  cecal  end.  Two  characteristic 
examples  of  carcinoma  limited  to  the  tip,  sent  me  by  C.  McBurney,  are  shown 
in  Figs.  374  and  375.     Attention  has  been  directed  to  the  fact  that  in  some  in- 


CARCINOMA. 


747 


stances  of  carcinoma  of  the  cecum  involving  the  appendix,  the  original  focus  may 
have  been  in  the  latter.  In  a  case  reported  by  Draper  (Bost.  Med.  and  Surg. 
Jour.,  1899,  vol.  38,  p.  180),  in  one  of  Keyi.ixc's,  and  in  one  of  Elting's  cases, 
it  cannot  be  definitely  determined  whether  the  growth  originated  in  the  appendix 
or  in  the  cecum.  In  a  case  of  carcinoma  of  the  cecum  involving  the  appendix, 
observed  in  Prof.  Halsted's  clinic,  the  possibility  of  an  appendiceal  origin  was 
considered. 

Gross    Appearance. — The  size  of  the  tumor  is  noted  in  18  cases. 
Of  these,  15  varied  from  5  to  12  mm.     In  Glazebrook's  case,  described  as 


Fig.  374. — McBurney's  Case  of 
Primary  Carcinoma  Limited 
to  the  tlp  of  the  a  i' i' km  >i  x. 
the  Remainder  of  which  is 
Normal. 


AH 


Fig.  375. — McBurney's  Case  of 

Primary  Carcinoma  of  the 

Tip  of  the  Appendix. 

There  is  a  slight  constriction 

proximal  to  the  growth  anil  the 

mucosa   is  somewhat  swollen   and 

hyperemia.     (Museum.  N.Y.,  No. 

2020.,) 


?r/"": 


Fig.  376.— H.  A.  Kelly.  Carci- 
noma of  the  Appendix. 
The  proximal  end  of  the  ap- 
pendix (a)  is  normal;  from  b  to  c 
there  is  a  distinct  thickening;  and 
beyond  this  area  the  lumen  is  di- 
lated (</).     (Spec.  No.  2854.) 


epithelioma,  the  tumor  was  the  size  of  a  pigeon's  egg  I  Virg.  Med.  Month.,  1895, 
vol.  23,  p.  186),  in  Beger's  the  size  of  a  walnut  {Bert.  klin.  Wochenschr.,  1882, 
vol.  19,  p.  616);  while  in  a  case  reported  by  Harth  and  Wilson  i  Med.  News,  11)02) 
the  growth  was  diffuse,  and  with  the  naked  eye  could  not  be  distinguished  from 
chronic  obliterative  appendicitis.  As  a  rule,  the  tumor  appeared  as  a  firm,  white 
nodule,  fairly  definitely  circumscribed.  Such  a  growth  upon  superficial  examina- 
tion may  readily  be  mistaken  for  a  simple  fibroma,  but  careful  inspection  reveals 
a  less  coarsely  fihrillated  structure  and  the  presence  of  homogeneous,  vellowish- 
gray  areas  studding  the  fibrous  tissue.     Furthermore,  while  the  tumor  appears  to 


748 


NEOPLASMS. 


be  generally  circumscribed,  it  cannot  he  shelled  out,  and  in  places,  the  margin 
gradually  merges  into  the  surrounding  tissue.  In  the  case  of  Harte  and  Wilson 
cited  above,  there  was  no  distinct  tumor,  but  a  general  invasion  of  almost  the 
entire  appendix  was  visible  under  the  microscope.  In  RoLLESTON's  case  the 
mass  presented  a  caseous  appearance  and  tuberculosis  was  suspected. 

Histologic    Examination  . — Only  a  few  of  the  cases  of  carcin- 


■ 


,-  ■   -■     I  - 


,' 


■   v 


-1. 


'Mm ' 


fsam^mm 


m$m 


Jr 


SS*.        -     ,w-       ^  V* 


• 


~* 


Fig.  377. — Section  from  the  Preceding  Case  of  Carcinoma  of  the  Appendix. 

The  lumen  (a)  is  almost  obliterated  by  the  encroachment  of  the  tumor,  which  has  apparently  originated  in  the 

mucosa  at  the  point  between  b  and  c.     Cell  nests  (d)  have  penetrated  all  the  layers. 


oma  of  the  appendix  conform  to  the  usual  type  of  glandular  intestinal  earcino- 
mata.  In  the  cases  reported  by  Beger  the  tumor  is  described  as  consisting  of 
proliferating  Lieberkuhn's  glands  (Arch.  /.  Chir.,  Bd.  18,  p.  306),  and  in  Kola- 
czek's  (Arch.  f.  klin.  Chir.,  1875,  Bd.  18.  p.  300)  a  distinct  glandular  structure  was 
apparent.  The  majority  of  cases  belong  to  a  less  usual  type,  consisting  of  round, 
oval,  or  irregular  alveoli  filled  with  small  polymorphous  cells,  having  a  scanty  pro- 
toplasm and  sharply  stained  vesicular  nuclei.    Mitotic  figures  are  seldom  abundant 


CARCINOMA. 


749 


and  may  be  scarce.  In  but  few  places  is  there  any  evidence  of  a  glandular  forma- 
tion. Generally,  however,  where  the  growth  is  traced  to  its  origin  in  the  mucous 
membrane,  a  lumen  may  be  detected  in  one  or  two  of  the  alveoli,  and  it  is  usually 
possible  to  trace  a  direct  histogenetic  relationship  between  the  tumor  and  the 
crypts  of  Lieberkiihn.  The  tumors  show  a  distinct  local  invasive  tendency 
penetrating  the  submucous  and  muscular  coats  with  but  few  exceptions.  In 
the  case  reported  by  Xorris  (Univ.  of  Perm.  Med.  Bull.,  1903.  p.  334)  the  cell 
nests  extended  into  the  mesappendix.  Out  of  11  cases  which  I  have  had  the 
opportunity  to  study  under  the  microscope,  including  a  case  reported  by  myself  in 
the  Johns  Hopkins  Hospital  Bull.,  1900  (see  Figs.  376,  377,  and  378),  9  were  of 


Fig.  378. — A    Small    Area    from    Fig.  377.     Enlarged    350    Times. 
Normal  crypts  of  Lieberkuhn  are  seen  at  a,  and  nests  of  tumor  cells  at  b;   c  indicates  the  stroma. 


this  variety,  one  a  distinctly  glandular  type,  and  one  a  colloid  carcinoma.  These 
tumors  in  their  histologic  and  their  gross  appearance  are  very  similar  to  a  group 
of  multiple  carcinomata  of  the  small  intestine  found  by  C.  Bunting  and  to  be 
reported  hereafter  (Johns  Hopkins  Hospital  Bull.).  From  a  study  of  one  case 
observed  and  the  few  recorded  in  the  literature,  this  writer  arrives  at  the  conclu- 
sion that  such  tumors  have  a  generally  benign  tendency,  and  bear  a  striking 
resemblance  to  the  basal-cell  carcinomata  of  the  skin,  described  by  Krompecher. 
Fnlike  the  tumors  observed  in  the  appendix,  these  tumors  of  the  ileum  were  all 
found  in  persons  of  advanced  years.  A  less  benign  tendency  is  noticeable  in 
the  appendical  tumors,  notwithstanding  the  fact  that  many  were  discovered 


750 


NEOPLASMS. 


accidentally  at  operation  or  at  autopsy.  In  3  instances  there  was  extensive  in- 
vasion of  the  surrounding  structures.  In  5  or  (i.  perforation  of  the  appendix 
with  consequent  peritonitis  had  occurred,  the  rupture  showing  a  definite  rela- 
tion to  the  new-growth.     In  other  instances  there  was  fairly  definite  evidence  that 


Fig.  :J79. — Colloid  Carcinoma  of  the  Appendix.  Discovered  at  Autopsy.     (From  A.  Elting,  Albany, N. Y.) 


a  carcinoma  of  the  cecum  was  secondary  to  the  appendical  growth.  De  Rtjyter 
(Arch.  j.  hlin.  Chir.,  Bd.  69,  p.  281)  relates  a  case  in  which  at  autopsy  a  carcinoma 
was  found  to  have  developed  in  the  stump  of  the  appendix,  which  had  been  re- 
moved six  years  previously.  Involvement  of  the  regional  lymph  glands  occurs 
apparently  late  in  the  disease,  and  was  observed  in  only  2  cases. 


CARCINOMA. 


r.5l 


Colloid  carcinoma  is  found  in  a  somewhat  larger  percentage  of 
the  cases  of  carcinoma  of  the  appendix  than  obtains  for  the  intestine  as  a  whole. 
Of  a  total  of  43  cases  recorded,  7,  or  26  per  cent.,  were  of  this  nature.  Of  these 
cases  4,  described  by  Rokitansky,  were  not  examined  histologically,  and  possibly 


s@i» 


■  -   "•It  *&•.-' -i*  c" 


mm 


7C:     ^'~ 


icnoN  utoM 


,'oi.loid   Carcinoma. 


a,  Gland  lined  with  cylindrical  epithelium:   b,  epithelial  celU.  colloid  degeneration;   c  beginning  degeneration 

the  cells;  d.  colloid  material;  c,  submucosa. 


of 


some  of  them  were  instances  of  simple  cystic  distention.  With  the  exception 
of  one  of  Eltixg's  cases,  these  growths  were  all  discovered  at  autopsy  (see  Figs. 
379  and  380). 

Etiology. — The  frequent  occurrence  of  chronic  obliterative  appendicitis  in 
association  with  the  carcinoma,  and  the  definite  relation  which  the  new-growth 


752  NEOPLASMS. 

sometimes  bears  to  stenosed  areas,  afford  strong  presumption  of  an  etiologic  rela- 
tionship. In  eases  described  by  Leti  i.le  and  Weinbxjhg,  and  by  Haute  and 
Wilson,  as  well  as  in  one  of  Eltixg's  eases,  there  was  distinct  evidence  of  chronic 
obliterating  inflammation.  In  2  <-ises  described  by  Letulle  and  Weinburg  the 
tumor  was  situated  at  a  point  of  stenosis,  the  result  of  several  attacks  of  appen- 
dicitis. It  has  been  frequently  pointed  out  that  malignant  growths  are  espe- 
cially prone  to  develop  in  atrophying  or  vestigial  structures.  The  appendix, 
therefore,  would  seem  to  afford  a  particularly  favorable  site  for  them. 

Mechanical  irritation  appears  to  play  an  unimportant  role  in  the  develop- 
ment of  tumors  in  the  appendix.  Considering  the  frequent  occurrence  of  car- 
cinoma following  stones  in  the  gall-bladder  and  bile-ducts,  it  is  somewhat  sur- 
prising how  few  cases  occur  similarly  in  the  appendix.  This  may,  perhaps,  be 
explained  by  the  fact  that  hard  concretions,  such  as  are  formed  in  the  gall- 
bladder and  its  ducts,  and  are  liable  to  injure  the  tissues,  are  less  common  in  the 
appendix,  most  of  the  so-called  concretions  consisting  of  inspissated  fecal  material, 
being  of  rather  soft  consistency.  Enteroliths  and  hard  bodies,  owing  to  the 
structure  of  the  appendix  and  the  abundant  bacterial  life,  often  determine  a  per- 
forative appendicitis;  therefore  the  appendix  is  not  subjected  to  the  long- 
continued  mechanical  irritation  which  obtains  in  the  case  of  calculi  in  the  gall- 
bladder. In  3  cases,  2  reported  by  Harte  and  WlLSON  and  one  by  myself, 
concretions  were  found,  but  they  showed  no  demonstrable  relation  to  the 
growth.  In  Case  3,  p.  745.  a  concretion  was  present  in  the  canal  immediately 
beyond  the  portion  involved  in  the  tumor. 

A  g  e  . — The  age  at  which  malignant  tumors  of  the  appendix  develop  is  espe- 
cially noteworthy.  Of  the  cases,  conclusively  shown  to  lie  instances  of  primary 
carcinoma,  the  ages  are  given  in  25  instances.  Four  of  these  were  under  twenty 
years  of  age.  11  between  the  ages  of  twenty  and  thirty.  The  youngest  patient 
was  a  girl  twelve  years  of  age.  operated  on  by  Jalagcier  for  recurrent  appendic- 
itis. In  this  case  the  tumor  was  situated  at  the  point  where  stenosis  had 
resulted  from  the  chronic  inflammation.  In  one  of  Eltixg's  cases  the  tumor 
was  found  at  autopsy  in  a  man  eighty-one  years  old.  and  one  of  Rokitaxsky's 
in  a  man  eighty-two  years  old.  These  were  both  instances  of  colloid  cancer. 
Of  the  cases  reported  above,  the  ages  were  respectively  twenty-four,  thirty,  and 
nineteen  years.  In  the  cases  of  sarcoma  the  patients  were  thirty-nine,  twenty- 
nine,  and  six  years  of  age.  The  correspondence  between  the  age  at  which  new- 
growths  so  often  occur  and  the  age  at  which  appendicitis  is  most  common,  sug- 
gests an  etiologic  relationship  between  the  two.  From  an  etiologic  standpoint 
it  may  also  be  noted  that,  at  an  early  age.  the  tip  of  the  appendix  is  often  under- 
going a  process  of  normal  involution  without  evidence  of  inflammation,  and 
in  several  of  the  recorded  cases  the  tumor  was  situated  in  the  tip,  while  the  re- 
mainder of  the  appendix  was  normal,  showing  no  trace  of  an  inflammatory 
proce--. 

Clinical  History. — The  clinical  symptoms  in  practically  all  cases  of  carcinoma 


CARCINOMA.  753 

of  the  appendix  which  come  to  operation  are  the  symptoms  of  chronic  appendic- 
itis, or  of  perforative  appendicitis  without  previous  evidence  of  appendical  disease. 
Of  the  cases  described  at  autopsy,  death  in  some  instances  was  due  to  general 
peritonitis  following  rupture  of  the  carcinomatous  appendix,  no  symptoms  of 
appendical  disease  having  existed  previous  to  the  fatal  attack;  in  others  the 
fatal  termination  was  the  result  of  the  extensive  invasion  of  neighboring  struc- 
tures by  the  growth;  and  in  other  cases  the  patient  had  presented  no  evidence 
of  disease  of  the  appendix  during  life,  death  being  due  to  some  intercurrent 
affection.  In  one  case  reported  by  Elting,  in  Jessop's  case,  in  Xorris's,  and 
in  my  own  the  condition  of  the  appendix  was  discovered  during  the  course 
of  an  operation  for  disease  of  the  pelvic  organs.  There  had  been  no  symptoms 
pointing  to  disease  of  the  appendix  in  these  cases.  The  clinical  history  of  appen- 
dical tumors,  therefore,  is  not  pathognomonic.  In  the  majority  of  cases  the  his- 
tory was  that  of  appendicitis  of  the  chronic,  relapsing  variety.  Pain  was 
the  most  constant  feature,  although  some  patients  were  free  from  it  during  the 
entire  course  of  the  disease.  When  present,  the  pain  was  usually  produced  by 
certain  movements,  or  by  active  exercise,  and  was  rarely  acute.  In  some 
instances  the  clinical  picture  resembled  that  of  recurrent  acute  appendicitis, 
the  patient  feeling  perfectly  well  in  the  intervals  between  the  attacks.  As  a  rule, 
digestion  was  normal  and  the  bowels  regular;  some  patients,  however,  suffered 
from  such  disturbances  of  digestion  as  usually  accompany  chronic  appendicitis. 
Alternating  diarrhea  and  constipation,  melena,  or  other  signs  indicating  a  new- 
growth  of  the  direct  intestinal  canal  were  never  observed. 

As  the  disease  progresses  peri-appendieal  abscess  is  a  common  sequela,  and 
in  one  case  in  which  the  abscess  was  opened  a  sinus  persisted  which  communicated 
with  the  lumen  of  the  appendix,  and  finally  became  lined  with  the  new-growth. 
In  this  case,  although  the  right  iliac  disease  was  present  for  three  years,  there 
was  no  disturbance  of  digestion.  The  iliopsoas  muscle  may  be  invaded  and  the 
ilium  eroded,  as  in  a  case  described  by  Kolaczek.  Extension  to  the  cecum  prob- 
ably occurs  in  a  considerable  number  of  cases.  In  Elting 's  case  the  complete 
destruction  of  the  distal  portion  of  the  appendix,  and  the  intimate  relation  of  the 
remaining  part  to  the  growth,  show,  fairly  conclusively,  that  the  carcinoma  was 
primary  in  the  appendix,  but  the  possibilty  that  it  had  originated  in  the  cecum 
cannot  be  denied.  When  the  cecum  has  become  implicated,  the  appendical 
lesion  is  masked  by  the  symptoms  arising  from  the  involvement  of  the  direct 
intestinal  canal;  viz..  disturbed  digestion,  alternating  diarrhea  and  constipa- 
tion, melena,  and  obstruction.  The  tumor  may  give  rise  to  an  attack  of  acute 
appendicitis  resulting  in  perforation  and  general  peritonitis.  Perforation  of  a 
carcinomatous  appendix  may  also  occur  without  previous  warning  of  the  pres- 
ence of  an  abnormal  condition.  Wright  described  an  autopsy  upon  a  case  of 
purulent  peritonitis  of  obscure  origin.  There  were  a  few  adhesions  about  the 
appendix,  but  no  definite  evidence  of  perforation.  As  a  routine  procedure, 
sections  of  the  appendix  were  made,  and  on  microscopic  examination  a  small 

4S 


754  NEOPLASMS. 

carcinoma  of  the  head  of  the  appendix  was  found,  and  just  at  the  junction  of 
the  tumor  with  the  bowel  there  was  a  minute  perforation  which  was  the  starting- 
point  of  the  infection.  The  growth  apparently  was  limited  to  the  appendix. 
A  similar  history  is  found  in  case  :!.  p.  745.  As  1  have  already  indicated,  it 
is  undoubtedly  because  carcinoma  of  the  appendix  has  a  tendency  to  give  rise 
to  perforation  or  gangrenous  inflammation  while  in  its  very  early  stages,  that 
so  few  cases  are  discovered. 

Diagnosis  and  Differential  Diagnosis. — With  one  or  two  exceptions  the 
recorded  cases  of  tumors  of  the  vermiform  appendix  were  discovered  at  opera- 
tion or  on  the  postmortem  table,  and  owing  to  the  similitude  of  the  clinical  pic- 
ture to  that  of  chronic  appendicitis,  it  is  impossible  with  our  present  methods 
of  examination  to  make  a  diagnosis,  clinically  at  least,  in  the  early  stages  of 
the  growth.  The  discovery  of  a  mass  in  the  right  iliac  region,  presenting  the 
characteristics  of  a  new-growth,  and  not  accompanied  by  the  signs  and  symp- 
toms usually  occasioned  by  a  tumor  involving  the  direct  intestinal  canal,  is  strongly 
presumptive  of  a  tumor  originating  in  the  appendix.  In  the  presence  of  a 
tumor  mass  the  differentiation  between  a  new-growth  and  inflammatory  condi- 
tions is  often  difficult.  In  some  cases  the  clinical  history  is  of  value.  A  sudden 
onset,  associated  with  high  temperature,  leucocytosis,  and  other  acute  symptoms, 
indicates  inflammatory  disease.  The  sudden  development  of  a  tumor  mass 
where  none  previously  had  existed  also  points  to  an  inflammatory  origin.  As  a 
rule,  a  new-growth  is  more  definitely  circumscribed,  not  so  firmly  fixed,  and 
is  less  sensitive  on  palpation.  In  Beger's  case  a  correct  diagnosis  was  made 
before  operation,  being  based  upon  the  fact  that  the  growth  which  lined  the 
abdominal  fistula  showed  the  typical  structure  of  intestinal  carcinoma,  that  it 
originated  in  the  region  of  the  appendix,  and  that  there  were  no  symptoms 
referable  to  disease  of  the  direct  intestinal  canal. 

Tuberculosis  of  the  hyperplastic  f  o  r  m  may  readily 
be  mistaken  for  a  new-growth.  The  more  cylindrical,  less  nodular  shape  of 
the  tubercular  tumor,  associated  with  the  presence  of  other  tubercular  foci,  are 
the  most  distinctive  features.  Bacilli  would  probably  not  be  found  in  the  stools, 
or  at  any  rate  but  rarely,  while  the  disease  is  limited  to  the  appendix.  The  tuber- 
culin test  may  possibly  aid  in  the  differential  diagnosis.  Fortunately,  in  all  these 
conditions  an  operation  is  indicated  ;  even  after  the  abdomen  is  opened  the  true 
nature  of  the  disease  is  not  always  recognized,  and  often  the  new-growth  when 
small  is  overlooked,  or  is  considered  to  be  simply  an  obliterating  appendicitis. 
This  is  of  little  moment  when,  as  is  often  the  case,  the  growth  occupies  the  tip 
of  the  appendix;  but  when  it  is  situated  near  the  cecal  end  it  is  of  vital  impor- 
tance. 

While  the  usual  mistake  is  that  of  considering  a  new-growth  to  be  a  simple 
inflammatory  condition,  the  converse  may  also  occur,  and  in  some  instances  a 
chronic  inflammatory  condition,  accompanied  by  excessive  tissue  production, 


CARCINOMA.  755 

has  given  the  impression  of  a  malignant  neoplasm.     The  following  case  is  a 
striking  example  of  the  diagnostic  difficulties  in  such  cases. 

J.  H.  H.,  Gym  No.  8751.  Negress,  age  twenty-four.  Admitted  with  a  history 
of  pelvic  pain,  dating  from  a  childbirth  two  years  previously.  The  pain  was  drag- 
ging in  character,  increased  on  exertion  and  relieved  by  recumbent  position.  There 
was  a  feeling  of  obstruction  on  defecation  and  at  times  considerable  pain;  there 
was  also  slight  bladder  irritation.  All  symptoms  had  been  much  worse  during  the 
past  five  or  six  months.  She  was  well  nourished,  her  tongue  clear,  temperature  and 
pulse  normal.  Examination  showed  the  pelvic  organs  normal  except  for  the  retro- 
posed  uterus.  In  the  ileocecal  region  there  was  a  mass  the  size  of  a  hen's  egg,  slightly 
irregular  in  outline,  of  rather  firm  consistency.  The  mass  could  be  moved  upward 
away  from  the  pelvic  brim,  but  could  also  be  brought  well  down  into  the  pelvis  on 
the  right  side.  On  opening  the  abdomen  the  mass  in  the  ileocecal  region  was  found 
to  involve  the  head  of  the  cecum;  it  was  about  the  size  of  a  hen's  egg  and  hard. 
The  appendix  was  not  seen.  As  the  mass  strongly  suggested  a  new-growth,  extir- 
pation of  the  entire  affected  area  was  decided  upon,  and  was  accordingly  done,  after 
which  an  end-to-end  anastomosis  was  made.  Examination  of  the  removed  struc- 
ture showed  a  retrocecal  appendix,  surrounded  by  a  mass  of  dense  inflammatory 
tissue. 

Similar  cases  are  described  by  Soxxexburg,  Fenger,  Gerster  and  others, 
and  have  been  cited  in  Chap.  XV. 

The  finding  of  a  distinct  tumor  in  the  appendix  should  always  be  regarded 
with  suspicion,  because  innocent  tumors  are  rare;  whereas  carcinoma  is  rela- 
tively common.  While  it  is  often  impossible  to  determine  the  true  nature  of 
the  growth  when  it  is  in  situ,  it  can  usually  Lie  recognized  in  the  gross  specimen 
by  examining  the  cut  surface  and  noting  the  relation  of  the  tumor  to  the 
appendical  walls.  In  doubtful  cases,  especially  if  a  wide  resection  of  the  bowel 
is  necessary,  frozen  sections  should  be  examined  at  once  during  the  operation. 

Prognosis. — The  time  which  has  elapsed  since  the  majority  of  the  cases 
of  carcinoma  have  been  operated  on,  is  too  short  to  permit  of  a  positive  state- 
ment regarding  the  prognosis.  Up  to  1900,  only  3  cases  had  been  discovered 
at  operation,  Beger's  in  18S2,  Stimson's  in  1896,  and  Weir's,  reported  in 
1903.  In  the  first  of  these,  extensive  invasion  of  surrounding  structures  had 
taken  place  at  the  time  of  operation.  I  have  not  been  able  to  obtain  the  later 
history  of  Stimson's  case.  Weir's  patient  remained  well  during  the  three  years 
he  was  under  observation.  Since  1900,  20  cases  have  been  operated  on.  All 
recovered  from  the  operation,  and  so  far  as  I  can  learn,  with  the  exception  of 
Rollestox's  case,  none  have  shown  evidence  of  recurrence.  Some  months 
after  operation  Rolleston's  patient  was  in  poor  health  and  the  possibility  of  a 
recurrence  of  the  growth  was  suspected.  McBuRNEY,  in  May,  1903.  wrote  me 
that  his  patient  (operated  on  eighteen  months  before)  was  in  good  health. 
Thorxdike's   patient    two   years  after  operation  gave  no  evidence  of    return 


756 


NEOPI.  \S\IS. 


of  the  growth.  The  case  which  I  reported  in  1900  shows  no  evidence  of  recur- 
rence at  the  present  time.  Monk's  case,  two  years  Later,  was  operated  on  for 
pelvic  inflammation,  and  at  that  time  there  was  no  evidence  of  recurrence. 
Burnam's  case,  operated  on  one  year  ago,  is  now  in  good  health.  Halstkd's 
patient  (case  3)  was  living  five  years  after  operation. 

Secondar  y  c  a  r  c  i  n  o  m  a  of  the  appendix  is  not  uncommon,  occur- 
ring most  frequently  by  direct  invasion,  apparently  more  often  by  contiguity 
than  by  continuity  of  structure,  and  occasionally  by  means  of  metastases.  In 
a  considerable  number  of  cecal  tumors  the  appendix   is   involved;  it  is  quite 


A .  Ho  r  n. 


Fig.  381. — H.  A.  Kelly.    Invasion  of  the  Tip  of  the  Appendix  by  Contiguity  from  a  Papillary  Carcinoma 
of  the  Ovary,     a,  Papillary  Carcinoma.      (Gyn.  Path.  No.  5607.) 


frequently  invaded  by  tumors  to  which  it  has  become  adherent ;  and,  naturally, 
it  is  involved  in  cases  of  general  abdominal  carcinosis.  Out  of  3  cases  of  malig- 
nant ovarian  tumors  to  which  the  appendix  had  become  adherent  (observed  in 
the  gynecological  service  of  the  Johns  Hopkins  Hospital),  in  2  the  growth  had 
invaded  the  appendical  walls  (see  Fig.  381),  and  in  another  case  a  non-adherent 
carcinoma  of  the  ovary  had  given  rise  to  metastasis  in  the  appendix.  In  these 
cases,  as  a  rule,  the  growth  had  penetrated  the  peritoneal  and  muscular  coats 
of  the  appendix,  but  had  not  involved  the  mucous  membrane.  In  a  case  re- 
ported by  Whipham,  a  small  carcinomatous  tumor,  situated  in  the  mucous  and 


SARCOMA. 


757 


submucous  layers  of  the  appendix,  and  associated  with  carcinoma  of  the  ovary 
accompanied  by  general  metastases,  was  regarded  as  primary,  on  account  of 
the  location,  but  it  was  probably  a  metastatic  growth  from  the  ovarian  tumor. 
Sarcoma. — Sarcoma  of  the  intestine  in  general  is  rare,  and  Xothnagel,  in 
his  enumeration  of  the  distribution  of  the  collected  cases,  did  not  note  its  occur- 
rence in  the  vermiform  appendix.     Lamers  (I.  D.  Giessen,  1902)  mentions  two 


Fig.  382. — Bernats'  Case  of  Sarcoma  of  the  Appendix  Involving  the  Adjacent  Portion  of  the  Cecum. 

(See  p.  760.) 


cases  in  the  cecum  and  one  in  the  appendix.  He  also  describes  a  new  case  of 
cecal  sarcoma  in  a  boy  six  years  old.  From  time  to  time  cases  of  sarcoma  of  the 
appendix  have  been  reported,  but  in  the  majority  of  these  the  description  is 
very  unsatisfactory.  Sonnenburg  merely  mentions  the  fact  that  he  has  seen 
a  case;  Gilford  describes  a  case  in  which  the  sarcomatous  tissue  had  formed 
around  a  concretion,  but  there  is  some  question  as  to  whether  he  was  not  dealing 


758 


XF.OPI.  \SMS. 


with  a  hyperplastic  inflammatory  process.  Undoubted  examples  of  sarcoma 
originating  in  the  appendix  arc  described  by  P.  Paterson  and  by  J.  C.  Warren, 
and  a  third  case  lias  been  furnished  me  by  A.  C.  Bernays  of  St.  Louis.     On 

account  of  the  rarity  of  sarcoma  of  the  intestine  and  of  the  especial  interest  at- 
tached to  these  cases  of  sarcoma  of  the  appendix,  a  brief  account  of  each  of 
these  is  given. 


W'&y-rWi-^-i    S 


8 


Fig.  :;s:;. — Section  from  the  Preceding  Case.  Showing  the  Diffuse  Infiltration  of  the  Walls  of  the 

Appendix  with  the  Sarcoma  Cells.     (See  p.  760.) 
The  crypts  of  Lieberkuhn  are  preserved  in  places,  but  the  struma  of  t he  mucosa,  the  submucosa,  and  trie  mus- 
cular coats  are  wholly  replaced  by  the  new-growth. 


1.  J.  C.  Warren.  (Bost.  Med.  and  Surg.  -lour..  1S9S.  vol.  138,  p.  177.)  A 
boy,  six  years  old,  entered  the  hospital  with  a  history  of  a  month's  illness  occasioned 
by  what  was  supposed  to  be  a  chronic  appendicitis  characterized  by  intermittent 
pain  in  the  appendical  region  and  slight  fever.  On  admission  there  was  a  small 
tumor  at  McBurney's  point.  He  was  kept  under  observation  for  ten  days,  during 
which  the  subjective  symptoms  subsided,  but  the  tumor  remained.  Operation 
showed  a  new-growth  in  the  ileocecal  angle,  instead  of  a  suppurative  inflammation, 


SARCOMA.  759 

the  surrounding  parts  being  more  or  less  glued  together.  The  mass  proved  to  con- 
sist of  the  greatly  enlarged  appendix,  which  was  the  size  of  a  thumb  in  diameter, 
and  of  enlarged  glands,  going  back  to  the  root  of  the  mesentery.  A  piece  excised 
for  examination  showed  round-cell  sarcoma.  The  cecum,  with  part  of  the  ileum 
and  corresponding  part  of  the  mesentery,  was  then  excised  and  the  intestine  anas- 
tomosed with  a  Murphy  button.  Complete  recovery  followed,  and  a  personal 
communication  in  1902.  four  years  after  operation,  stated  that  the  boy  was  enjoy- 
ing excellent  health,  with  no  evidence  of  recurrence. 

2.  P.  Patekson.  (Practitioner.  1903.  p.  55.)  A  man,  thirty-nine  years  old, 
gave  a  history  of  uneasiness  in  the  right  iliac  fossa  for  three  months,  with  occasional 
attacks  of  sharp  pain,  lasting  for  several  days.  His  bowels  were  constipated  during 
the  acute  attacks,  but  otherwise  normal :  he  had  never  had  any  vomiting.  When 
first  seen,  the  patient  was  suffering  from  an  acute  attack,  characterized  by  severe 
pain  in  the  right  iliac  fossa,  nausea,  and  anorexia.     His  temperature  was  100.8°  F. ; 

-  ••■  ;°-  *:-f-A 

,  s        - 


b 

Fig.  384. — Higher  Magnification-  of  Fig.  383.     Sarcoma  of  the  Appendix.     (X    290.) 

The  section  shows  closely  packed,  round  cells  (a),  having  large  vesicular  nuclei  which  vary  somewhat  in  size  and 

staining  properties;  c  indicates  nuclear  division;  delicate  blood  capillaries  (b)  traverse  the  held. 

his  pulse  100.  Palpation  revealed  a  distinct,  tender  mass  in  the  right  iliac  fossa. 
On  operation  the  appendix  was  found  much  thickened,  firm,  and  bound  down 
by  adhesions  posteriorly,  while  the  omentum  was  attached  to  its  apex.  The  cecum 
was  also  thickened  for  a  radius  of  about  one-fourth  of  an  inch  around  the  attachment 
of  the  appendix.  The  appendix,  together  with  the  thickened  part  of  the  cecum. 
was  removed,  and  the  opening  closed.  The  patient  never  rallied  from  the  operation 
and  died  six  hours  later.  Postmortem  examination  failed  to  show  any  trace  of 
tumor  formation  elsewhere,  and  the  part  of  the  cecum  that  remained  in  situ  ap- 
peared healthy.  The  appendix  was  16.5  cm.  long  and  10  cm.  in  its  greatest  cir- 
cumference. The  growth  had  apparently  begun  near  the  apex  of  the  appendix  and 
extended  toward  the  cecum,  which  was  only  slightly  infiltrated.  Histologic 
examination  showed  a  round-cell  sarcoma  infiltrating  all  the  coats  with  the 
exception  of  the  peritoneum. 

3.  A.  C.  Beknats,   1902.     (Personal  communication.)     A  woman,  twenty-nine 


760  NEOPLASMS. 

years  old,  with  a  good  family  history,  and  both  parent.';  living,  had  been  in  good  health 
up  tn  cine  year  before  her  illness.  She  then  began  to  have  periodical  attacks  of  pain 
in  the  right  side  of  the  abdomen,  and  was  referred  to  Bernays  with  a  diagnosis  of 

appendicitis.  A  hard  tumor  could  then  be  plainly  felt.  Operation  was  deferred 
for  a  few  days,  because,  although  the  hard  tumor  was  what  might  have  been  ex- 
pected after  an  acute  attack  of  appendicitis,  the  temperature  was  normal.  On 
opening  the  abdomen,  the  appendix  was  found  free  in  the  peritoneal  cavity;  it  was 
Id  cm.  long,  and  apparently  normal  in  its  distal  half,  but  in  its  proximal  portion 
it  was  greatly  enlarged  and  firm  to  the  touch,  the  infiltration  involving  the  adjacent, 
wall  of  the  cecum  for  a  short  distance  on  one  side  (see  Fig.  382).  A  complete  exci- 
sion of  the  cecum  was  made,  and  the  patient  made  an  excellent  recovery.  Histo- 
logic examination  showed  a  typical  round-cell  sarcoma  infiltrating  all  the 
layers  of  the  appendix  (see  Figs.  383  and  384).  The  cells,  which  were  fairly  regular 
in  size  and  in  their  staining  properties,  showed  very  active  nuclear  division.  The 
distal  portion  of  the  appendix  was  normal.  I  have  not  had  an  opportunity  to 
examine  the  wall  of  the  cecum  beyond  the  growth.  A  note  just  received  from 
Rernays  states  that  now,  September,  1904,  two  years  after  the  operation,  a  tumor  is 
again  present  in  the  abdomen,  which  is  probably  a  recurrent  growth. 


CHAPTER  XXXII. 
CLINICAL  HISTORY   OF  THE  SPECIFIC  INFECTIONS. 

TUBERCULOSIS.     ACTINOMYCOSIS.     AMCEBIC  DYSENTERY. 

TUBERCULOSIS. 

Intestinal  tuberculosis  is  mostly  secondary,  occurring  in  the  last  stages  of 
lung  tuberculosis.  In  such  cases  the  resistance  of  the  organism  is  so  slight  that 
the  lesions  become  widely  distributed  over  the  intestine,  and  ulcers  showing  no 
tendency  to  heal  are  produced,  which  frequently  advance  to  perforation  with 
consequent  fatal  peritonitis.  In  a  considerable  proportion  of  these  cases  the 
perforation  occurs  in  the  appendix.  Intestinal  tuberculosis  is  of  especial  impor- 
tance when  localized  in  the  ileocecal  region.  In  such  cases  the  disease  is  usually 
primary,  or  if  secondary  has  a  comparatively  insignificant  focus  in  some  other 
organ,  usually  the  lung.  The  organism  still  having  the  strength  to  limit  the 
tubercular  process,  the  lesions  show  a  tendency  to  healing  with  cicatrization  of 
the  ulcers,  or  to  infiltration  and  connective-tissue  proliferation  (Lexzmaxx). 

It  has  long  been  known  that  the  ileocecal  region  is  the  favorite  site  for  the 
localization  of  intestinal  tuberculosis,  whether  secondary  or  primary,  and  since 
Hartmaxx  and  Pilliet  in  1890  called  attention  to  the  occurrence  of  the  tumor- 
like tuberculous  lesions  in  the  intestine,  this  form  of  the  disease  has  been  found 
to  be  almost  constantly  confined  to  the  ileocecal  region.  Infection  of  the  appen- 
dix commonly  occurs  by  direct  continuity  from  the  cecum,  or  as  a  local  mani- 
festation of  a  general  infection;  an  infection  of  the  bowel  secondary  to  pulmo- 
nary tuberculosis,  however,  may  be  entirely  localized  in  the  appendix.  I'exwick 
and  Dodwell  (Lancet,  1894,  vol.  2,  p.  133)  found  that  in  17  cases  occurring 
among  2000  autopsies  on  persons  dying  of  tuberculosis,  the  intestinal  ulcera- 
tion was  limited  to  the  appendix.  Furthermore,  the  appendix  is  often  invaded 
through  direct  contact  with  a  tubercular  tube  or  ovary.  Thus,  out  of  7  instances 
in  which  I  have  found  the  appendix  adherent  to  the  diseased  pelvic  organs,  in 
4  the  tubercular  process  had  invaded  the  wall  of  the  appendix.  In  one,  the 
appendix  was  involved  in  a  general  peritoneal  tuberculosis,  secondary  to  the 
tubal  disease  (see  Fig.  38">).  Primary  tuberculosis  of  the  appendix  is  appar- 
ently very  rare.  It  is  difficult  to  judge  of  its  exact  frequency,  because  in  the 
absence  of  postmortem  demonstration,  the  presence  of  other  foci  cannot  be 
positively  excluded;  while,  on  the  other  hand,  many  cases  undoubtedly  pass 
unrecognized,  owing  to  their  resemblance,  both  clinically  and  macroscopically, 
to  ordinary  acute  or  subacute  appendicitis. 

761 


762 


CLINICAL    HISTORY    OF   TII10    Sl'KCIFK '    INFF.CTIONS. 


A  few  cases,  however,  have  been  described  in  which  the  evidence  strongly 
pointed  in  a  primary  affection  of  the  appendix,  and  was  confirmed  by  the  com- 
plete restoration  of  the  patient's  health  after  the  appendix  had  been  removed. 

The  only  definite  examples  which  1  have  been  able  to  find  are  the  cases  of  the 
usual  ulcerative  form  described  bySoNNENBi  rg,  and  by  McCosh  and  Hawkes, 
and  a  case  of  hyperplastic  tuberculosis  described  by  Crowder.  Mosher  de- 
scribes a  case  in  which  at  operation  the  tubercular  infection  seemed  limited  to 

the  appendix,  but  three  years  later  the  patient  died  of  pulmonary  tuberculosis. 

An  additional  case  has  been  sent  me  by  F.  HENROTIN  of  Chicago,  and  two  others 

have  come  under  my  own 
observation,  one  in  my  priv- 
ate hospital,  and  the  other  in 
the  practice  of  my  associate, 
T.  S.  CuLLEN.  The  nature 
of  the  lesions  in  these  cases 
was  wholly  unsuspected,  until 
it  was  discovered  in  the  course 
of  the  routine  laboratory  ex- 
amination of  the  specimen. 
A  third  case,  operated  on  for 
acute  appendicitis,  was  found 
on  microscopic  examination 
to  present  advanced  tuber- 
cular lesions,  but  on  account 
of  some  thickening  in  the 
walls  of  the  cecum  observed 
during  the  operation,  as  well 
as  owing  to  the  presence  of 
hardened  cervical  glands,  it 
seemed  probable  that  the 
lesion   of   the  appendix   was 

secondary.     The  clinical  notes  of  the  cases  are  as  follows:* 

1.  F.  Henrotin.  (Personal  communication.)  A  woman,  twenty-one  years 
old,  was  admitted  to  a  hospital  with  a  history  of  severe  pain  accompanied  by  vomit- 
ing, occurring  at  each  menstrual  period.  The  first  attack  occurred  eighteen  months 
before  --lie  was  seen,  but  there  was  no  recurrence  until  six  months  later,  since  which 
time  it  had  accompanied  every  period.  The  attacks  began  with  pain,  very  severe 
on  the  right  side  and  slight  on  the  left.  Vomiting  followed  in  a  few  hours.  The 
spontaneous  pain  ceased  when  menstruation  ended,  lint  tenderness  in  the  right  side 
was  almost  constantly  present.  The  bowels  were  fairly  regular,  but  the  patient 
suffered  from  indigestion,  and  had  become  considerably  thinner  than  usual.  At 
operation  the  appendix  was  found  elongated,  thickened,  and  adherent  to  the  iliac 

*  For  pathological  description  see  Chap.  XV. 


Fig.  385. — Peritoneal  Tuberculosis   Involving  the   Appen- 
dix,    WHICH      HAS      BECOME      PARTLY     TWISTED    ON      ITS    AXIS. 

(Mrs.  P..  April  12,  1902.; 


TUBERCULOSIS.  763 

fossa  at  its  apex  by  web-like  adhesions;  there  were  also  a  few  adhesions  near  its 
base.  It  was  removed  by  the  usual  cuff  operation,  and  a  portion  of  the  right  ovary, 
which  was  cystic,  was  also  removed.  The  result  was  primary  union,  with  entire 
recover}'  from  the  previous  symptoms,  and  no  evidence  of  tubercular  disease  (Fig. 
204). 

2.  T.  S.  Cullex.  The  patient,  an  unmarried  woman,  twenty-three  years  old, 
whose  family  and  personal  history  were  unimportant,  had  complained  for  about 
a  year  of  dull  pain  in  the  right  lower  abdomen.  There  had  been,  however,  no  acute 
attacks.  Apart  from  the  local  condition,  the  physical  examination  was  negative; 
the  temperature  was  normal.  At  operation  the  appendix  was  found  to  be  brightly 
injected,  and  its  surface  presented  a  pock-marked  appearance;  it  was,  however,  free 
from  adhesions.  There  was  no  other  evidence  of  abdominal  disease.  The  patient 
made  an  uneventful  recovery  and  was  relieved  of  her  symptoms.  Histologic  exami- 
nation showed  extensive  tubercular  invasion  of  the  mucosa  and  submucosa,  with 
slight  involvement  of  the  muscularis. 

3.  S.  Q.,  San.  Xo.  1309.  Feb..  1902.  Thirty-two  years  old,  married.  Marked 
family  history  of  tuberculosis.  The  patient  had  had  pleurisy  when  twenty  years 
old,  also  "inflammation  of  the  bowels"  followed  by  diarrhea  lasting  for  two  year-, 
and  cystitis.  Two  months  before  coming  under  my  care  myomectomy  had  been 
performed,  but  the  bladder  symptoms  and  bearing-down  pain  in  the  pelvis,  from 
which  she  suffered,  continued.  There  were  no  signs  of  appendical  disease  and  no 
physical  evidence  of  tuberculosis.  Operation  showed  extensive  pelvic  disease  with 
adhesions  involving  the  uterus,  tubes,  and  ovaries,  as  well  as  the  appendix,  which 
was  atrophied  and  adherent  behind  the  colon.  It  was  3.5  cm.  long  and  4  mm.  in 
diameter,  covered  with  adhesions,  and  its  canal  was  totally  obliterated.  There  was 
nothing  in  its  gross  appearance  to  suggest  tuberculosis,  but  under  the  microscope  it 
was  found  that  the  mucosa  and  submucosa  were  entirely  replaced  by  typical  tuber- 
cular tissue.  Tubercle  bacilli  were  found,  but  with  difficulty.  .Six  months  later 
the  patient  wrote  that  except  for  the  continued  bladder  irritability,  she  was  in  ex- 
cellent health  and  was  gaining  in  weight. 

4.  Sonxenburg.  (Perityphlitis,  1900,  p.  68.)  The  patient  was  a  single  woman 
who  gave  a  history  of  recurrent  appendicitis  extending  over  a  period  of  three  years. 
There  was  an  indefinite  resistance  in  the  right  iliac  fossa,  which  was  slightly  tender 
on  deep  palpation.  There  was  no  evidence  of  any  tubercular  affection  of  the  lungs 
or  other  organs,  and  no  family  history  of  tuberculosis. 

5.  McCosh  and  Hawkes.  (Amer.  Jour.  Med.  Sci..  1902.)  The  only  state- 
ment made  in  regard  to  this  case  is  that  the  symptoms  from  which  the  patient 
suffered  were  evidently  due  to  pyosalpinx  and  to  appendicitis.  The  inflamma- 
tion of  the  appendix  was  found  on  microscopic  examination  to  be  tubercular,  the 
pyosalpinx  non-tubercular. 

6.  Chowder,  Chicago.  {Personal  communication.)  A  man  forty-seven  years 
old.  whose  father  had  died  of  tuberculosis,  gave  a  history  of  griping  pain  in  the  abdo- 
men beginning  several  months  before  he  was  seen.  The  pain  had  been  of  only  a  few 
minutes'  duration  until  the  last  few  weeks,  when  it  increased  in  frequency  and  in 
severity,  and  after  about  ten  days  it  was  accompanied  by  nausea  and  once  by  vomit- 
ing. There  was  pain  and  tenderness  in  the  right  iliac  fossa.  On  admission  to  the 
hospital  there  was  a  tender  swelling  in  the  region  of  the  appendix,  extending  down 


Tlvl  CLINICAL    HISTORY   OF  THE   SPECIFIC   INFECTIONS. 

to  Poupart's  ligament.  The  next  afternoon  the  temperature  was  100°  F.,  but 
thereafter  it  remained  normal.  Eight  days  later  all  spontaneous  pain  had  disap- 
peared, the  swelling  was  much  reduced  in  size,  and  pressure  gave  only  an  indistinct 
sense  of  tenderness.  At  operation,  performed  a  week  later  by  C.  Fengeh,  the 
enlarged  appendix,  including  a  portion  of  the  cecal  wall  which  was  moderately 
thickened,  was  removed.  There  was  no  evidence  of  peritoneal  tuberculosis.  Heal- 
ing took  place  without  complications.  Two  weeks  after  operation  the  patient 
developed  an  acute  orchitis,  on  the  right  side,  which  gradually  subsided,  but  on 
account  of  some  induration  persisting,  an  incision  was  made  three  months  later; 
no  evidence  of  tuberculosis,  however,  was  discovered.  When  seen  eighteen  months 
later,  the  patient  reported  perfect  health  and  showed  no  signs  of  local  recurrence 
or  any  evidence  of  tuberculosis  in  any  other  pari  of  the  body  (Figs.  205, 206,  and 
207)/ 

An  analysis  of  these  lew  eases  shows  that  apart  from  the  family  history  of 
tuberculous  disease  in  two,  and  the  indefinite  history  of  antecedent  tubercular 
foci  in  one,  there  were  no  signs  nor  symptoms  by  which  the  affection  could  be 
distinguished  from  simple  chronic,  or  subacute  appendicitis.  The  irregular 
diarrhea,  or  alternating  constipation  and  diarrhea,  often  found  with  tuberculosis 
of  the  direct  intestinal  canal,  was  not  observed,  nor  was  there  ever  any  blood 
in  the  stools.  With  the  exception  of  t'ase  1,  the  general  health  of  the  patient 
was  not  affected.  The  detection  of  the  specific  organism  in  the  stools  would  be 
a  valuable  aid  in  the  diagnosis,  but,  while  the  disease  is  limited  to  the  appen- 
dix, it  is  not  apt  to  be  present.  The  tuberculin  test  would  be  only  of  negative 
value,  as  it  is  impossible  to  exclude  other  foci.  Moreover,  its  use  is  scarcely 
justifiable,  since  operation  is  advisable  in  any  case.  These  cases  of  localized 
tuberculosis,  as  I  have  said  before,  are  essentially  chronic,  and  have  a  tendency 
to  undergo  fibrous  transformation;  it  is  apparently  but  seldom  in  an  early  stage 
that  they  are  the  source  of  a  more  general  infection.  As  a  rule,  adhesions  are 
present,  which  in  the  event  of  a  perforation  would  tend  to  limit  the  infection  to 
the  right  iliac  region.  Involvement  of  the  regional  lymph  glands,  however,  is 
frequent,  and  the  invasion  of  the  ileocecal  region  is,  finally,  extremely  extensive. 

When  tuberculosis  of  the  appendix  has  involved  the  neighboring  portion  of 
the  cecum,  or  when  it  merely  accompanies  a  primary  cecal  or  general  intestinal 
affection,  the  symptoms  are  masked  by  those  of  a  more  pronounced  character 
produced  by  the  latter  disease.  In  the  ordinary,  widely  disseminated,  ulcerative 
tuberculosis  of  the  bowel, which  occurs  in  the  late  stages  of  a  large  proportion  of 
all  cases  of  lung  tuberculosis,  the  gastro-intestinal  symptoms  are  general,  and  are 
characterized  chiefly  by  anorexia,  by  more  or  less  constant  diarrhea,  abdominal 
pain,  irregular  pyrexia,  and  frequently  by  the  passage  of  mucus  and  blood  in  the 
stools.  When  the  affection  is  localized  in  the  right  iliac  fossa,  acute  symp- 
toms are  seldom  observed,  and  the  disease  may  advance  so  insidiously  that  the 
first  evidence  of  its  presence  is  the  occurrence  of  sudden  acute  intestinal  obstruc- 
tion, or  of  perforation. 


TUBERCULOSIS. 


765 


In  a  recent  case  of  T.  S.  Cullen's,  the  patient,  who  was  a  strong-looking  Irish 
woman,  twenty-four  years  old,  gave  a  history  of  abdominal  cramps  occurring  two 
or  three  times  a  month  for  about  a  year,  in  addition  to  which  she  was  somewhat 


I 


Perfo  ration- 


ft 


-*„ 


r-.xW- . 


J I  e.  u  nv 


Fig.  386. — T.   S.    Cullen's  Case  of  Inflammatory  Thickening  with  Tuberculous  Stricture  of  the  As- 
cending Colon  Followed  by  Perforation  of  the  Colon  just  Above  the  Cecum. 
Tuberculous  lymph  (-lands  present   at   ileocecal  angle.     Resection  and  end-to-end  anastomosis.     Recovery. 

(Natural  size.) 


constipated.  For  about  a  week  before  admission  to  the  hospital  she  had  inter- 
mittent pains  in  the  right  abdomen,  and  the  night  before  operation  she  was  taken 
with  a  severe  pain,  followed  by  a  movement  of  the  bowels.     The  following  mom- 


766 


CLINICAL    HISTORY    OF   THE    SPECIFIC    INFECTIONS. 


ing  she  was  able  to  attend  to  her  usual  duties,  but  in  the  evening  was  again  seized 
with  acute  pain  in  the  region  of  the  appendix.  When  seen  about  two  hours  later, 
there  was  marked  rigidity  of  the  muscles  over  the  appendix  region,  with  slight 
fever,  pulse  full  and  regular.  Examination  of  the  blood  showed  a  total  absence 
of  eosinophils,  which  was  the  chief  indication  for  an  early  operation,  performed 


Fig.  387. — Cross-section  of  the  Preceding. 
Showing  the  great  thickening  of  the  bowel  at  the  point  of  stricture,  and  its  funnel-shaped  orifice  completely  oc- 
cluded by  a  shot.     The  point  of  perforation  is  seen  on  the  left. 


four  hours  later.  There  was  then  found  a  perforation  of  the  cecum,  consequent 
upon  an  almost  complete  stenosis,  due  to  the  cicatrization  of  an  old  annular 
tubercular  ulcer  (see  Figs.  386  and  387). 

The  onset  of  the  ileocecal  affection  is  usually  indefinite,  the  earliest  symp- 
toms, as  a  rule,  consisting  of  dyspepsia,  anorexia,  nausea,   irregular  diarrhea, 


TUBERCULOSIS. 


r67 


and  slight  fever.  When  stenoses  have  formed,  symptoms  of  chronic  obstruction 
are  common.  Colicky  pains  in  the  abdomen  and  more  or  less  flatulency,  most 
marked  in  the  cecal  region,  constipation  alternating  with  diarrhea,  and  some- 
times vomiting,  are  then  prominent  symptoms.  The  stools  may  show  nothing 
characteristic;  sometimes  there  is  a  great  deal  of  mucus,  and  occasionally  blood. 


Jleo-  cecal     valve 


Tuberculous     areas 


Fig.  388. — Finney's  Case  of  Tuberculosis  of  Cecum  and  Appendix  Extending  up  into  Colon. 
Resection  and  anastomosis,  March  25,  1903.     L.  .1..  female,  age  twenty-six.     (Natural  size.) 


In  the  case  shown  in  Fig.  388  (Surg.  Xo.  14506)  there  was  a  history  of  frequent 
stools,  with  severe  attacks  of  gastric  pain  and  distention,  slight  elevation  of 
temperature,  and  emaciation  extending  over  a  period  of  three  years.  There  was 
a  marked  family  history  of  tuberculosis.  The  stools  contained  much  mucus, 
but  no  blood,  and  search  for  tubercle  bacilli  was  negative.     The  abdomen  felt 


7G8  CLINICAL   HISTORY   OK   THE   SPECIFIC   INFECTIONS. 

somewhal  boggy,  but  there  was  no  especial  tenderness.    The  temperature  was 
99.5°  1  ■'. ;  the  leucocyte  count  was  ")600. 

The  hyperplastic  form  of  tuberculosis  develops  very  insidiously.  Colicky 
abdominal  pain,  at  first  occurring  at  long  intervals,  but  becoming  progressively 
more  acute  and  more  frequent,  is  the  most  constant  symptom.  The  later 
symptoms  are  usually  those  of  gradually  advancing  obstruction,  accompanied 
with  evening  pyrexia,  emaciation,  and  loss  of  strength.  In  some  cases  recur- 
rent acute  attacks,  closely  simulating  recurrent  appendicitis,  are  the  mosl 
prominent  features  in  the  clinical  history.  As  a  rule,  however,  the  patient  does 
not  entirely  recover  in  the  intervals.  The  most  conspicuous  physical  sign  is 
the  presence  of  a  tumor  in  the  right  iliac  fossa.  This  may  be  so  prominent  as 
to  be  noticeable  on  mere  inspection.  It  is  more  or  less  cylindrical,  somewhat 
nodular,  and  as  a  rule  possesses  slight  or  no  mobility.  It  is  somewhat  tender, 
but  rarely  acutely  so.  The  disease  may  closely  simulate  a  new-growth  of  the 
cecal  region,  or  a  peri-appendical  exudate.  The  age  incidence  of  the  disease 
corresponds  with  that  of  carcinoma.  The  most  distinctive  features  in  the 
diagnosis  are  the  gradual  development  and  the  character  of  the  tumor,  which 
is  more  sharply  outlined  and  less  tender  than  a  perityphlitic  mass,  while  it  is 
less  nodular  than  a  carcinoma  and  more  nearly  preserves  the  normal  contour 
of  the  bowel.  The  shape  may  strikingly  resemble  that  of  a  sarcoma.  The 
latter  condition,  however,  is  too  rare  to  complicate  the  diagnosis  frequently. 
The  detection  of  tubercle  bacilli  in  the  stools  is  of  positive  value,  pointing 
directly  to  intestinal  tuberculosis,  because,  as  mentioned  above,  this  localized 
tubercular  process  is  seldom  complicated  with  active  tuberculosis  elsewhere, 
so  that  the  possibility  of  other  sources  for  the  organisms  need  not  be  considered. 


ACTINOMYCOSIS. 

Actinomycosis  hominis  has  only  recently  come  to  be  regarded 
as  anything  more  than  a  pathologic  curiosity.  Murphy  in  18S5  reported  the 
first  case  in  America,  but  since  then  over  100  cases  have  been  reported  in  this 
country  by  W.  S.  Ekvixg  (Johns  Hopkins  Hospital  Bull.,  1902),  while  Illich 
(Beit.  z.  klin.  AM.,  Wien,  1892)  collected  421  cases  from  the  literature.  In 
about  20  per  cent,  of  these  cases  the  disease  was  localized  in  the  abdomen,  and 
in  the  majority,  the  infection  atrium  was  the  vermiform  appendix.  Four  cases 
of  actinomycosis  affecting  the  right  side  of  the  abdomen  have  been  observed  in 
the  Johns  Hopkins  Hospital,  3  in  the  surgical  department  and  1  in  my  own 
clinic.  The  clinical  histories  of  these  cases  were  so  strikingly  similar  that  only 
one  case  will  be  cited  as  an  example. 

J.  H.  H.,  Gyn.  No.  6961.  A  negress,  twenty-eight  years  old.  had  spent  most 
of  her  life  on  a  farm.  Five  months  before  admission,  while  in  good  health  and  hav- 
ing had  no  symptoms  of  intestinal  trouble,  she  was  suddenly  seized  with  intense 


ACTINOMYCOSIS.  769 

colicky  pain  in  the  right  lower  abdomen.  The  pain  continued  several  weeks,  and 
at  the  end  of  the  first  week  a  swelling  the  size  of  a  hen's  egg  was  noticed  in  the 
region  of  the  appendix.  This  swelling  gradually  spread  throughout  the  entire 
lower  abdomen.  About  a  week  before  admission  a  small  sinus  appeared  in  the 
vicinity  of  the  umbilicus  discharging  puriform  material.  The  mass  was  hard  and 
board-like  and  the  abdominal  walls  densely  infiltrated.  The  temperature  was 
remittent,  ranging  from  99°  to  100°  F.,  with  a  Ieucocytosis  of  12.000.  An  inci- 
sion in  the  median  line  opened  into  a  large  necrotic  cavity  in  the  abdominal  wall. 
The  tissue  removed  showed  actinomycotic  infiltration.  There  was  no  attempt  at 
healing,  although  the  temperature  fell  to  normal.  About  four  weeks  later,  ex- 
tensive lateral  incisions  were  made  and  the  potassium  iodide  treatment,  begun  a 
few  days  before,  was  continued.  Marked  improvement  was  then  observed,  the 
induration  almost  disappeared,  and  the  incisions  healed  rapidly;  but  a  few 
weeks  afterward  pain  made  its  appearance  in  the  right  thoracic  region,  accom- 
panied with  fever.  Two  weeks  later  there  was  a  severe  chill,  followed  by  a  rise  of 
temperature  to  106°  F. ;  the  leucocytes  at  the  time  were  5800.  There  was  tender- 
ness over  the  liver  and  increase  in  its  area  of  dulness.  A  few  days  before  death, 
three  months  from  the  time  of  admission,  definite  signs  of  lung  involvement 
appeared  (see  Fig.  208). 

Etiology. — The  disease  is  probably  contracted  from  grain,  or  from  infected 
animals.  It  is  most  commonly  found  in  farmers,  cattlemen,  and  those  concerned 
with  the  management  of  live  stock  or  grain.  In  some  instances  there  is  a  definite 
history  of  caring  for  infected  animals,  and  in  several  of  the  reported  cases  a  grain 
of  wheat  or  barley  has  been  found  in  the  midst  of  the  actinomycotic  mass.  Men 
seem  to  be  more  frequently  attacked  than  women,  the  proportion  being  about  3 
to  1 .  The  difference  may  be  plausibly  explained  by  the  fact  that  men  are  more  fre- 
quently employed  about  animals,  and  in  handling  grain,  and  more  often  have  the 
habit  of  putting  grains  or  straw  into  the  mouth.  Any  age  may  be  affected,  but 
the  disease  is  most  frequent  about  middle  life.  It  may  rim  a  very  slow  course  or 
may  develop  rapidly.  In  one  instance  it  continued  only  four  weeks,  in  another 
thirteen  years  (Ervixg),  but.  as  a  rule,  the  course  is  chronic,  the  parts  affected 
early  showing  a  tendency  to  heal,  while  new  foci  are  developing  elsewhere.  In 
the  abdominal  cases  the  clinical  history  at  the  outset  resembles  appendicitis. 
The  onset  is  often  acute,  and  is  characterized  by  the  occurrence  of  sharp,  cramp- 
like abdominal  pains,  which  continue  more  or  less  constantly  for  a  few  days  or 
weeks,  then  subsiding  and  perhaps  not  recurring  for  two  or  three  months.  Gener- 
ally, however,  after  the  acute  attack  has  subsided,  more  or  less  soreness  persists 
and  a  tender  swelling  is  noticed  in  the  appendical  region.  In  a  case  related  by 
L.  Thedexot  (X.  Y.  Med.  Rec.  1900)  the  patient,  a  young  man,  aged  eighteen, 
who  had  been  a  groom,  gave  a  history  of  a  sudden  attack  of  violent  and  contin- 
uous pain  in  the  right  iliac  fossa.  He  improved,  and  operation  was  advised. 
On  admission  there  was  no  pain,  but  great  lassitude  and  anorexia.  The  appen- 
dix, which  was  apparently  slightly  inflamed  and  swollen,  was  removed  and  a 

49 


77(1  CLINICAL    HISTORY   <  >F  THE   SPECIFIC   INFECTIONS. 

gauze  drain  left  in.  The  wound  healed  slowly  and  a  very  hard  mass  formed 
in  contact  with  the  appendix  stump,  which  appeared  to  increase.  Examination 
of  scrapings  showed  the  ray  fungus,  which  had  not  been  found  in  the  appendix. 

In  the  4  cases  observed  in  the  Johns  Hopkins  Hospital  the  onset  was  marked  by 
sudden,  severe  colicky  pains,  occurring  without  warning  while  the  patient  was 
in  good  health,  and  not  accompanied  with  nausea,  vomiting,  or  other  gastro- 
intestinal symptoms.  The  temperature  is  usually  hut  slightly  elevated  in  the 
early  stages,  but,  owing  to  the  liability  of  mixed  infection  supervening  in  the 
abdominal  cases,  a  septic  temperature  accompanied  with  chills  frequently  devel- 
ops. The  leucocytes  vary  greatly,  in  some  cases  being  almost  normal,  in  others 
numbering  28,000  to  36,000.  As  the  disease  advances  the  most  characteristic 
sign  is  the  progressive  increase  in  the  mass  and  the  brawny  infiltration  of  the 
tissues.  The  rigid,  hoard-like  abdominal  walls  are  not  found  in  any  other  condi- 
tion. Practically  the  whole  abdomen  may  be  involved,  the  older  foci,  as  I 
have  said,  retrogressing  while  others  form.  The  infection  gradually  extends 
to  the  surface,  when  sinuses,  often  multiple,  appear  and  discharge  a  reddish- 
yellow  puriform  material,  which  is  often  extremely  offensive.  The  character- 
istic sulphur  granules  are  then  usually  seen.  In  rare  instances  the  disease  spreads 
superficially  and  remains  localized  in  the  intestinal  mucous  membrane.  Two 
cases  only  (Canali  and  Chiari)  have  been  described  (0.  Daske,  /.  I).  Griefswald, 
1902).  Hofmeister  (Beit.  j.  klin.  Chir.,  1900,  Bd.  26,  p.  344)  describes  two  un- 
usual cases  in  which,  without  extension  to  the  neighboring  structures,  there  was 
great  thickening  of  the  walls  of  the  appendix  and  cecum,  which  might  have  been 
confused  with  neoplasm,  especially  sarcoma,  or  with  hyperplastic  tuberculosis. 
In  such  a  case  the  nature  of  the  disease  is  recognized  by  the  appearance  of  the 
characteristic  granules  in  the  stools.  The  final  event  in  the  course  of  the  disease 
is  the  occurrence  of  metastases,  with  the  development  of  nodules  in  the  lungs, 
heart,  brain,  liver,  and  other  organs. 


AMEBIC  DYSENTERY. 

Amoebic  dysentery  is  of  interest  in  connection  with  diseases  of  the  vermiform 
appendix,  on  account  of  the  comparatively  frequent  occurrence  of  perforation  of 
this  organ  as  a  fatal  complication  of  the  disease.  Rogers,  who  has  observed  a 
large  number  of  cases  in  India,  finds  that  the  appendix  is  often  severely  affected 
and  is  especially  liable  to  become  perforated.  As  a  rule,  symptoms  referable  to 
the  appendical  involvement  cannot  be  distinguished  from  the  symptoms  pro- 
duced by  the  lesions  in  the  cecum  and  colon.  The  distinctive  features  of  the  dis- 
ease are  the  "  irregular  diarrhea,  marked  by  exacerbations  and  intermissions,  and 
progressive  loss  of  strength  and  flesh."  The  stools  are  often  bloody  or  mucoid 
at  the  outset,  but  later  their  chief  characteristic  is  their  fluidity.  The  detection 
of  the  amoeba  in  the  stools  is  the  only  positive  evidence  of  the  nature  of  the  dis- 
ease.    In  the  event  of  a  perforation  the  characteristic  symptoms  of  perforative 


AMCEBIC    DYSENTERY.  771 

peritonitis  develop,  and  when  the  patient  has  been  known  to  be  the  victim  of  the 
amoebic  affection,  the  onset  of  peritonitis  and  its  cause  are  readily  recognized. 
In  somewhat  rare  instances  where  acute  symptoms  are  absent  the  nature  of  the 
dysentery  is  not  recognized,  and  in  such  a  case  the  sudden  development  of  symp- 
toms of  perforative  appendicitis  may  be  referred  to  a  simple  appendicitis.  As 
prompt  surgical  intervention  is  indicated  in  either  case,  this  is  of  less  importance, 
and  at  operation  the  characteristic  lesions  are  usually  easily  recognized. 


CHAPTER  XXXIII. 

OPERATIVE  TREATMENT  OF  NEOPLASMS  AND  SPECIFIC 

INFECTIONS. 

DISEASE  LIMITED  TO  THE  APPENDIX.     DISEASE  IN  THE  ILEOCECAL  REGION. 

OPERATION  FOR  DISEASE  LIMITED  TO  THE  APPENDIX. 

Tumors. — The  operation  for  removal  of  a  polyp,  a  myoma,  or  a  car- 
cin  o  m  a  of  the  appendix  differs  in  no  important  respect,  as  a  rule,  from  the 
extirpation  of  the  appendix  for  other  causes. 

P  o  1  y  p  s  of  the  appendix,  so  far  as  they  have  yet  been  observed,  appear 
to  be  little,  soft  tumors,  which  may  not  be  discovered  before  the  removal  of  the 
organ,  or  if  they  attract  attention  earlier,  are  simply  noted  as  enlargements  of  its 
lumen. 

Myomata,  on  the  other  hand,  in  the  three  cases  reported,  were  little  nodules, 
not  unlikely  to  be  mistaken  for  chronic  inflammatory  thickening;  they  might 
also  be  mistaken  for  carcinoma. 

The  carcinomat  a  (adeno-  and  colloid)  are  the  only  other  tumors  limited 
to  the  appendix.  The  a  d  e  n  o  -  c  a  r  c  i  n  o  m  a  t  a  ,  which  have  never  yet 
been  diagnosed  before  operation,  appear,  as  a  rule,  as  little  circumscribed  nodules, 
usually  associated  with  peri-appendicitis,  and  in  several  instances  with  perfora- 
tion. Bearing  in  mind  the  marked  characteristics  of  this  affection,  and  the 
fact  that  it  occurs  with  a  frequency  hitherto  unsuspected,  as  shown  by  the  num- 
ber of  collected  cases  (see  Chap.  XXXI),  operators  will,  no  doubt,  be  more 
alert  in  future  concerning  it,  and  more  ready  to  suspect  the  nature  of  the  disease 
with  which  they  have  to  deal,  even  before  it  is  established  by  microscopic  exami- 
nation. An  incision  through  the  nodule  while  the  patient  is  on  the  operating 
table,  will  often  give  unmistakable  evidence  to  a  practised  eye.  The  treatment 
is  a  wide  excision  extending  well  into  the  mesenteriolum,  and  a  painstaking 
investigation  for  glandular  metastases.  Where  the  disease  has  extended  beyond 
the  appendix  into  the  neighboring  cecum,  a  resection  of  the  appendix,  together 
with  a  wide  resection  of  the  cecum,  is  the  proper  course.  This  method  must 
also  be  pursued  in  those  cases,  carefully  noted,  in  which  the  disease  has  localized 
itself  near  the  base  of  the  appendix.  In  two  instances  in  which  the  glandular 
metastases  were  so  far  advanced  that  an  operation  was  out  of  the  question,  there 
was  no  cecal  involvement  whatever. 

I  know  of  but  one  case  of  c  o  1 1  o  i  d   carcinoma  of  the  appendix  which 

772 


OPERATION'S    FOR   ILEOCECAL   TUMOR.  773 

has  been  the  subject  of  operation,  and  this  was  Elting's.  Elting's  other  case 
(Chap.  XXXI,  Figs.  379  and  380)  was  one  in  which  it  will  be  seen  from  the 
reproductions  that  the  mass  could  easily  have  been  extirpated,  as  it  was  per- 
fectly localized  in  the  appendix. 

The  only  cases  of  sarcoma  of  the  appendix  which  have  been  operated  upon, 
so  far  as  I  know,  are  those  of  J.  C.  Warren,  P.  Paterson,  and  A.  C.  Bernays 
(see  Chap.  XXXI,  p.  758  to  p.  760).  In  each  of  these  the  appendix  was 
enlarged  and  thickened  and  the  disease  extended  a  short  distance  upward  into 
the  cecum.  In  operation  upon  one  of  them  the  excision  was  made  just  beyond 
the  growth,  while  in  the  other  two  the  entire  cecum  was  extirpated. 

Tuberculosis. — A  simple  tubercular  process  limited  to  the  appendix  may 
assume  an  obliterati  v  e  f  o  r  m  like  that  of  a  uterine  salpingitis,  or  it 
may  appear  as  an  acute  appendicitis,  with  ulceration  of  the  mucosa  and  surround- 
ing adhesions.  Such  cases  need  no  special  comment  from  a  surgical  standpoint, 
as  they  differ  in  no  way  from  other  appendicitides  to  the  naked  eye,  and  the 
nature  of  the  process  is  discoverable  only  after  a  microscopic  study  of  the  part 
removed.  In  Crowder's  case  of  hyperplastic  tuberculosis 
("appendicitis  tuberculosa  hyperplastica")  not  only  was  the  diameter  of  the 
organ  much  enlarged,  but  the  disease  extended  up  into  the  neighboring  cecum 
as  well.  The  removal  of  the  disease  was  effected  by  an  excision  including  the 
cecum,  a  procedure  which  requires  no  special  description. 


OPERATIONS  FOR  ILEOCECAL  TUMORS. 

The  fact  that  tumors  in  the  ileocecal  region  are  frequently  confused  with 
appendicitis  convinces  me  that  their  surgical  treatment  ought  to  be,  at  least, 
briefly  described  here. 

Extensive  operations  upon  the  ileocecal  region  with  resection  of  the  cecum, 
of  a  part  of  the  ileum,  or  of  the  ascending  colon,  or  of  both,  are  still  more  recent 
in  their  origin  than  operations  for  appendicitis. 

The  first  case  reported  was  that  of  H.  Kraissold,  in  April,  1889  (Yolkm. 
Samml.  klin.  Yortr.,  No.  191;  and  Central,  f.  Chir.,  1881,  p.  186);  it  was  per- 
formed for  carcinoma  attributed  to  a  blow  from  a  stone,  received  six  years 
previously.  The  patient  was  a  man,  sixty-two  years  old,  who  had  suffered  for 
thirteen  months  from  two  fistulas  with  extensive  fecal  discharge.  The  cancerous 
disease  involved  the  vermiform  appendix,  the  cecum,  and  the  ileocecal  valve, 
all  of  which  were  excised,  the  head  of  the  ileum  being  united  to  the  end  of  the 
colon  by  Lembert  sutures.  The  patient  unfortunately  died  of  collapse  in  two 
and  a  half  hours;  at  autopsy  the  bowel  was  found  tightly  closed;  there  was 
involvement  of  one  mesenteric  gland,  and  a  small  metastasis  was  found  in  the 
liver. 

The  first  successful  operation  was  done  by  Maydl,  in  1882  (Wien.  med. 
Presse,  1883,  p.  438).     R.  Suchier,  in  18S9,  reported  what  I  believe  to  be  the 


771         OPERATIVE   TREATMENT   OF    NEOPLASMS   AND   SPECIFIC    INFECTIONS. 

first  successful  operation  for  tubercular  stricture  of  the  ileocecal  region  (Berl. 
klin.  Woch.,  1889,  p.  617),  treating  it  by  excision  and  an  end-to-end  anastomosis, 
and  resecting  about  20  cm.  of  the  cecum  and  colon,  the  valve  not  being  in  the 
excised   portion. 

W.  S.  McGllL,  in  an  admirable  monograph,  the  first  in  the  English  language 
upon  this  subject  {Ann.  Surg.,  L894,  vol.  20,  p.  642),  says  that  Czerny,  in  1884, 
resected  the  ileocecal  valve  for  imagination  on  finding  the  valve  cancerous. 

WASSILIEF  in  1886  did  a  resection  to  cure  an  artificial  anus  established  for 
an  acute  invagination;  and  Czehny  again  resected  in  1892,  this  time  for  tuber- 
culosis. 

In  1894,  when  McGill's  article  was  published,  he  was  able  to  collect  104  opera- 
tions, undertaken  for  various  causes  on  tumors  in  the  ileocecal  region,  up  to 
that  date,  and  there  presented.  The  subject  has  also  been  ably  discussed  by 
Kocher  (Dtsch.  Zeit.  /.  Chir.,  1891);Czerny  (Beit.  z.  klin.  Chir.,  1890,  Bd.  6); 
Konig  (Arch.  /.  klin.  chir.,  1S90.  Bd.  40);  Sachs  (Arch.  j.  klin.  Chir..  1892,  Bd. 
143,  p.  123);  Korte  (Dtsch.  'Aril.  /.  Chir.,  1895,  Bd.  40);  Hofmeisteb  (Beit.  z. 
klin.  Chir..  1896,  Bd.  17,  p.  .">77);  and  Conrath,  in  a  monograph  over  100  pages 
in  length  on  "Chronic  local  rend  tuberculosis"  (Beit.  z.  klin.  chir..  1898,  Bd. 
21,  p.  h. 

Methods  of  Operation. — The  first  efforts  of  the  surgeon  should  be  directed 
to  the  discovery  of  the  exact  nature  <  if  the  disease,  as  the  operation  will  necessarily 
be  more  or  less  extensive,  according  as  he  has  to  deal  with  a  mass  of  a  simple 
inflammatory  or  tubercular  nature,  or  with  a  carcinomatous  or  sarcomatous 
growth.  He  must,  therefore,  bear  carefully  in  mind  all  the  data  furnished  by 
the  history,  since  these  often  suggest  a  probable  diagnosis  in  advance  of  the 
inspection  of  the  parts  in  situ.  A  history  of  a  pulmonary  tuberculosis,  or  a  t  uber- 
cular  process  elsewhere,  makes  ileocecal  tuberculosis  probable;  moreover,  in 
such  cases  the  patient  is  sometimes  cachectic  for  a  long  period,  and  is  more  apt 
to  have  suffered  from  stricture  and  obstruction.  Carcinoma  also,  however, 
may  run  an  indolent  course,  and  any  marked  cachexia  may  be  wanting  until  the 
later  stages  of  the  disease.  Bloody  stools  are  more  apt  to  be  associated  with 
carcinoma. 

A  long  oblique  incision,  either  transmuscular  or  in  the  semilunar  line,  should 
be  made  in  order  to  expose  the  whole  diseased  area  and  give  abundant  room 
for  the  subsequent  extirpation.  The  disease  will  be  studied  to  better  advantage 
if  the  incision  is  made  somewhat  toward  the  median  line.  As  a  preliminary 
measure,  the  mass  is  then  inspected  and  its  size,  its  extent  up  and  down  the 
bowel,  and  its  amount  of  fixation  noted;  the  possibility  of  an  enucleation  can 
then  be  roughly  determined.  The  operator  next  turns  his  attention  to  the 
rest  of  the  abdominal  cavity  in  order  to  secure  the  valuable  data  furnished  by 
metastases,  which  may  at  once  determine  the  nature  of  an  affection  which  is 
puzzling  even  after  the  abdomen  is  opened.  This  investigation  assumes  the 
more  importance  from  the  fact  that  Durande,  Billroth,  and  Hartmann  and 


METHODS   OF   OPERATION'   FOR   ILEOCECAL   TUMOR.  775 

Pilliet  (Soc.  anat.  de  Paris,  July  and  Dec,  1891),  as  well  as  Salzer  (Langerib. 
Arch.,  Bd.  43),  have  shown  that  it  is  often  impossible 
to  distinguish  a  tuberculous  process  from  one  can- 
cerous in  nature  while  it  is  still  situated  in  the  body; 
it  may  also  be  impossible  even  when  the  r  e  s  e  c  t  e  d 
bowel  is  removed  from  the  body  and  held  in  the  hand. 
Recalling  this  fact,  the  surgeon  will  treat  every  uncertain  case  as  though  it  were 
a  carcinoma,  giving  the  patient  the  benefit  of  the  doubt.  When  the  abdomen 
is  open,  and  before  any  steps  are  taken  to  pack  off  the  intestines  as  a  protec- 
tion from  any  subsequent  manipulations,  the  nature  of  the  affection  may  some- 
times, as  I  have  said,  be  at  once  determined  by  inspecting  the  metastases.  A 
tubercular  process  may  be  disseminated  all  over  the  abdomen,  or  it  may  be  dis- 
cernible only  in  the  form  of  characteristic  little  granules  situated  at  the  focus  of 
the  disease,  in  the  neighborhood  of  the  ileocecal  valve.  Again,  in  tuberculosis 
the  omentum  may  be  infiltrated  with  tubercles;  and  multiple  strictures  of  the 
bowel,  if  present,  speak  for  tubercular  disease.  As  Cohx  has  shown  (I.  D. 
Freiburg,  1902),  skin  fistula  as  a  complication  is  more  frequent  in  tuberculosis 
than  in  malignant  disease;  24  out  of  48  tuberculous  tumors  in  his  investiga- 
tion having  been  complicated  by  fistula,  while  Matalakowski's  statistics 
showed  only  2  complicating  fistulas  out  of  17  carcinomatous  tumors,  and  of 
these  2,  only  one  was  spontaneous.  The  smaller  number  of  fistulas  in  carci- 
noma may  to  some  extent  be  accounted  for,  however,  by  the  fact  that  malig- 
nant disease  is  apt  to  destroy  life  before  it  has  progressed  so  far. 

The  h  y  perplastic  form  of  tuberculosis  is  that  which  most  often  gives 
rise  to  errors  in  diagnosis  under  circumstances  so  favorable  as  those  just  de- 
scribed. One  of  the  most  characteristic  signs  of  tuberculosis  as  a  disease  is  the 
presence  of  caseous  glands  in  the  mesentery.  The  surgeon  must  also  examine 
the  omentum,  for  this  may  be  converted  into  a  carcinomatous  roll  extending 
transversely  across  the  abdomen  in  the  umbilical  region,  and  so  dense  that  it  can 
be  felt  even  before  the  incision  is  made;  this  condition,  when  it  exists,  affords  a 
grave  prognosis.  Carcinomatous  nodules,  if  not  present  on  the  peritoneum, 
may  be  found  lodged  in  the  deepest  part  of  the  pelvis.  Another  point  in  diag- 
nosis is  that  the  density  of  the  carcinomatous  nodules  situated  over  the  vertebral 
column,  differs  from  that  of  nodules  caused  by  the  tubercular  process.  The  pylo- 
rus, the  liver,  and  the  spleen  should  also  be  inspected  or  palpated  for  any  malig- 
nant masses.  In  some  instances  an  inflammatory  process  of  unusual  character 
arising  from  an  appendicitis  has  transformed  the  bowel  into  a  mass  so  rigid  that 
it  has  been  mistaken  for  malignancy  and  extirpated.  Such  an  accident  happened 
to  one  of  my  associates,  who,  not  doubting  the  malignant  nature  of  the  disease, 
and,  therefore,  the  urgent  necessity  of  an  extirpation,  amputated  the  cecum 
with  the  appendix  and  anastomosed  the  ileum  into  the  colon  end-to-end.  "With 
this  possibility  in  mind,  the  operator  should  not  allow  the  simplest  inflammations 
to  pass  unsuspected,  where  the  conditions  admit  of  any  doubt  at  all ;  in  an  urgent 


770       OPERATIVE   TREATMENT   OF    NEOPLASMS    AND  SPECIFIC   INFECTIONS. 

case  he  may  even  make  a  small  incision  into  the  neighboring  healthy  bowel  and 
introduce  his  finger,  in  order  to  investigate  sufficiently  to  put  the  question  at 

rest. 

An  actinomycotic  process  is  recognized  by  the  characertistic 
yellow  granules  and  by  its  tendency  to  extend  in  every  direction  into  all  contigu- 
ous tissues,  without  respect  to  natural  anatomic  barriers.  Acti  n  o  m  y  c  0- 
s  i  s  ad  v  a  n  c  es  l>  y  c  on  tin  u  i  t  y  and  c  on  t  i  g  u  i  t  y  a  1  i  k  e  , 
and    this    is    I  ru e    o f    n  o    0 t h  e  r    a  f  f  e  c  t  i  o  n  . 

The  real  nature  of  the  disease  having  been  determined  by  this  direct  method 
of  autopsy  in  vivo,  the  nexl  question  which  arises  is:  S  h  all  t  h  e  o  pe  ra  - 
t  i  o  n  proceed  fart  h  e r  t  h  a  n  the  si  m  pie  explorato r y 
incision'.'  The  answer  depends  upon  two  factors:  first,  the  vital  status 
of  the  patient,  that  is,  whether  he  is  much  exhausted  or  not  ;  second,  the  stage 
to  which  the  disease  has  advanced  and  its  complications.  As  regards  the 
patient,  it  may  he  said  at  once  that  the  present  tendency  is  to  exaggerate 
lack  of  vitality  and  power  of  resistance.  It  is  astonishing  how  much  a  weak 
patient  will  often  stand,  if  the  operation  is  skilfully  performed,  without  much 
exposure,  chilling,  and  handling  of  the  intestines,  and.  above  all,  if  the  adjacent 
parts  are  so  protected,  both  during  the  operation  and  subsequently  by  drainage, 
that  a  peritonitis  will  not  tread  right  upon  the  heels  of  an  exhausting  operation. 
Much  here  depends  upon  the  skill  and  experience  of  the  operator,  and  every 
man  who  deliberately  undertakes  a  delicate  and  difficult  task  of  this  kind  ought, 

at  least,  to  have  previously  performed  a  number  of  successful  resections  upon 
dogs.  Such  an  occasion  is  neither  the  time  nor  the  place  for  maiden  experi- 
ence! 

As  regards  the  stage  and  extent  of  disease,  there  can  lie  no  doubt  that  a 
radical  operation  should  be  carried  out  when  there  is  a  reasonable  hope  of  a  suc- 
cessful issue,  immediate  and  remote.  If  a  carcinoma  is  so  far  advanced  in  its 
invasion  of  other  parts  that  a  speedy  recurrence  of  the  symptoms  is  to  be  looked 
for,  it  will  not  he  wise  to  extirpate  the  primary  focus  in  the  cecum,  and  a  better 
plan  is  to  do  an  entero-anastomosis,  short-circuiting  the  affected  area. 

In  tuberculosis  and  in  actinomycosis  the  outlook  in  al tacking  a  great  mass 
of  diseased  tissue  is  more  cheerful,  since  it  is  well  known  that  in  these  conditions 
perfect  and  permanent  relief  may  follow  a  successful  anastomosis  after  enuclea- 
tion. Fig.  388  (Chap.  XXXII,  ]>.  767)  shows  an  extensive  tuberculous  area  in 
the  appendix,  the  cecum,  and  the  ascending  colon,  extirpated  by  Finney,  while 
Figs.  liSC)  and  387  (Chap.  XXXII.  pp.  765,  766)  represent  an  older  form  of  the 
disease  in  which  the  patient  suffered  from  the  resulting  stricture.  This,  as  shown 
in  Fig.  387,  was  reduced  to  the  calibre  of  a  small  shot,  and,  marvellous  to  relate, 
a  grain  of  shot  had  actually  entered,  and  engaged  itself  in  the  minute  orifice  so 
as  to  occlude  it  completely!  The  stenosed  bowel  had  found  an  outlet  for  the 
alvine  contents  in  the  perforation  shown  in  both  pictures. 

The  different  appearance  of  a  carcinoma  is  well  shown  in  Fig.  38(1,  which 


METHODS   OF   OPERATION    FOR    ILEOCECAL   TUMOR. 


Ill 


represents  a  case  of  my  own,  that  closely  simulated  an  appendicitis  in  the  pres- 
ence of  febrile  crises  with  localized  pain  and  tenderness.  The  only  suspicious 
circumstance  was  the  indolent  nature  of  the  rather  hard  mass.  The  appearance 
peculiar  to  carcinoma  is  shown  in  the  cross-section  a. 


Colon 


.  /Jorn.  fa. 


Fig.  389. — Carcinoma  of  the  Ileocecal  Valve  (a)   Extending  into  the  Cecum  (b)  Closely  Simulating 

Appendicitis. 

The  ridge  indicated  the  limits  of  the  disease.     Operation,  H.  A.  Kelly,  A.  McC,  San.,  Feb.  3.  1903;    resection 

and  end-to-end  anastomosis.     Death  from  recurrence  sixteen  months  later.      (Natural  size.) 


The  alternative  operations  in  any  given  case  are: 

1.  A  simple  exploratory  incision,  associated,  it  may  he. 
with  the  drainage  of  an  abscess  in  carcinoma  or  in  actinomycosis;  any  further 
attempt  to  operate  upon  the  bowel  being  abandoned,  on  account  of  the  patient  s 
condition  or  the  advanced  character  of  the  disease. 

2.  Simple    e  n  t  e  r  o  -  e  n  t  e  r  o  s  t  o  in  y  ,  by   means  of  a  lateral  anas- 


tomosis  of  a  loop  of  ileum  above  the  disease  to  the  colon  below  it,  thus  short- 
circuiting  the  diseased  area. 

3.  C  o  in  pie  te    exel  us  i  o  n    o  f    the    (lis  e  a  s  e  d    a  r  e  a  ,  effected 

by  amputating  the  bowel  above  it,  and  closing  the  end,  or  the  ends  leading  into 
and  out  of  the  affected  portion,  at  the  same  time  anastomosing  the  healthy  bowel 
from  above,  to  a  point  below  the  disease. 

4.  Extirpation  of  the  diseased  appendix  and 
cecum,  with  so  much  of  the  ileum  and  the  ascending  colon  as  may  be 
necessary,  followed  by  the  anastomosis  of  the  ileum  with  the  colon. 

If.  after  the  extirpation  of  the  diseased  portion  of  the  bowel,  the  patient's 
condition  is  such  that  it  is  impossible  to  proceed  with  the  operation  of  anasto- 
mosis, the  ends  of  the  bowel,  distal  and  proximal,  may  be  brought  out  onto  the 
surface,  so  as  to  establish  an  anus  pretematuralis.  This  should  be  closed  by 
completing  the  anastomosis  at  a  later  date,  which,  of  course,  simply  makes  two 
steps  of  the  fourth  alternative,  and  is  only  to  be  adopted  on  account  of  urgent 
necessity. 

The  s  e  c  o  n  d  alt  e  r  n  a  t  i  ve  ,  a  simple  entero-enterostomy,  short-circuit- 
ing but  incompletely  excluding  the  diseased  area,  is  most  valuable  in  cases  of 
advanced  disease,  where  removal  is  out  of  the  question,  or  where  the  patienl  has 
suffered  so  long  from  obstruction  that  his  condition  will  only  admit  of  the  most 
essential,  life-saving  operation.  An  entero-enterostomy  by  means  of  lateral 
anastomosis  of  a  loop  of  the  bowel,  to  the  ascending  or  transverse  colon,  is  the 
quickest  and  the  simplest  method,  as  well  as  that  which  affords  most  security  of 
overcoming  the  difficulties,  and  giving  prompt  relief  from  the  most  urgent  symp- 
toms. In  10  cases  out  of  Conrath's  list  a  simple  ileo-colostomy  was  done:  in  one, 
on  account  of  the  extent  of  adhesions;  in  two,  on  account  of  disseminated  tuber- 
culosis and  the  weakness  of  the  patient ;  in  one,  because  an  abscess  was  present  as 
well  as  adhesions;  in  one,  to  avoid  shock  from  prolonged  operation,  a  cholecys- 
tectomy having  preceded  the  cecal  operation;  in  one,  on  account  of  a  fresh 
tubercular  disease  in  the  chest;  and  in  one.  on  account  of  chronic  Bright's 
disease  and  general  weakness.  In  4  closely  noted  cases  the  tumor  was  observed 
to  grow  smaller  after  the  exclusion  of  the  diseased  area,  the  difficulties  disappear- 
ing; and  in  7  the  patients  were  reported  either  as  well,  or  steadily  improving. 
In  one  case  (Korte)  in  which  resection  of  the  diseased  area  was  not  made  on 
account  of  the  extensive  adhesions,  the  ileum  was  joined  to  the  colon  just  beyond 
the  disease  by  a  lateral  anastomosis.  Ten  months  later  the  operator  was  able 
to  extirpate  the  now  movable  tumor,  amputating  the  ileum  above  the  anasto- 
mosis and  implanting  it  anew  into  the  transverse  colon.  Recovery  followed. 
Conratb  concludes  that  the  late  results  of  a  simple  entero-anastomosis  for 
tubercular  cecal  tumor  are  to  be  reckoned,  from  every  standpoint,  among 
the  very  best. 

In  performing  an  entero-enterostomy,  the  first  point  of  importance  is  to  unite 
the  nearest  free  loop  of  the  ileum  to  the  colon  just  beyond  the  diseased  area, 


METHODS    OF    OPERATION    FOR    ILEOCECAL    TUMOR. 


779 


in  order  to  short-circuit  the  disease  effectively,  and  yet  not  throw  om  of  function 
any  more  of  the  bowel  than  is  necessary.  In  selecting  a  loop  of  the  ileum  for 
anastomosis  into  the  colon,  the  surgeon  must  always  bear  in  mind  the  definite 
disposition  of  the  small  intestinal  coils  in  the  abdomen,  which,  not  unlike  the 
convolutions  of  the  brain,  are  subject  to  minor  variations,  but  in  their  general 
grouping  are  always  the  same.  This  fact  will  be  best  understood  by  consulting 
Fig.  390,  showing  the  mesenteric  ruffle,  which,  of  course,  corresponds  precisely 


Fig.  390. — The  Mesenteric  Ruffle  Showing  the  Groups  and  Disposition  of  the  Coils  of  the  Ileum. 
A  and  B  occupy  the  left  and  right,  splenic  and  hepatic  flexures  of  the  colon  respectively,  and  should  always 
be  avoided  in  any  colic  anastomotic  operations.     E  lies  in  the  small  pelvis  and  is  thus  easily  distinguished;  more 
care  must  be  taken  in  distinguishing  C  and  D. 


to  the  arrangement  of  the  intestinal  coils  that  have  been  removed  to  facilitate 
the  demonstration.  The  groups  may  be  conveniently  lettered  and  designated 
from  duodenum  to  cecum,  as  Group  A,  Group  B,  Group  C,  Group  1),  and  Group 
K,  the  capital  letter  marking  the  centre  of  its  group,  which  is  limited  by  the 
small  letters  preceding  and  following.  The  surgeon  will  at  once  perceive  that 
if  he  were  to  pick  up  a  loop  of  intestine  under  the  left  colic  flexure  from  Group 
A,  he  would  short-circuit  almost  the  entire  intestinal  canal,  and  starvation  of 


780       OPERATIVE   TREATMENT   OK    NEOPLASMS   AND  SPECIFIC   INFECTIONS. 

his  patient  would  inevitably  result.  The  mistake  he  is  most  likely  to  make  is 
to  take  a  loop  in  B,  and  attach  it  to  the  ascending  or  the  transverse  colon, 
thus  committing  the  serious  error  of  throwing!  rroups  C,  1),  and  E  out  of  function. 
The  anastomosis  should  he  made  in  E,  which  must  he  picked  up  and  drawn  over 
to  the  colon;  or  it  must,  at  any  rate,  not  he  higher  than  1),  in  case  K  is  too  much 
involved  in  adhesions,  as  shown  in  Fig.  391,  taken  from  an  actual  case  of  von 
Kiselsbf.ho.  The  bowel,  thus  brought  up,  should  lie  in  easy  apposition,  with- 
out  folds,    flexures,   twists,   or  undue  traction.     The  methods  of  making  the 


FlG.  391. — Anastomosis  of  a  Loop  of  the  Ileum  into  the  Transverse  Colon,  after  a  Case  of  von  Eiselb- 

berg  {Arch.  /.  Win.  Chir.,  B<1.  56,  p.  303J. 
The  last  group  ami  the  ascending  colon  were  not  available  here  on  account  of  the  extensive  adhesions. 


anastomosis  are  the  same  as  those  employed  for  lateral  anastomosis,  shown 
in  Figs.  392  and  393.  Previous  to  the  anastomosis  the  diseased  area  has  been 
extirpated  and  the  ends  closed. 

Complete  exclusion,  the  third  alt  e  r  n  a  t  i  v  e  ,  includes,  according  to 
Wolfleu  (Verhandl.  d.  dtsch.  Gesell.  f.  Chir..  1889),  unilateral  as  well  as  bilateral 
occlusion  of  the  diseased  portion.  If  a  unilateral  occlusion  is  done,  the  ileum  is 
amputated  above  the  disease  and  the  proximal  end  anastomosed  into  the  colon  by 
an  end-to-side  or  a  side-to-side  anastomosis,  while  the  distal  end,  leading  into  the 
diseased  portion,  is  closed  by  suture.     A  complete  bilateral  exclusion  is  effected 


METHODS   OF   OPERATION    FOR    ILEOCECAL   TUMOR. 


781 


when  the  diseased  bowel  is  cut  free  from  the  healthy  ileum  above  and  the  colon 
below,  yet  is  not  removed.  Experience  and  experiment  have  shown  that  the 
sequestrated  portion  must  have  an  exit,  and  this  may  be  provided  in  bad  cases, 
by  a  fistula  (as  in  3  out  of  8  cases  in  Conrath's  collection),  or  by  bringing 
one  or  both  cut  ends  onto  the  surface.  In  one  case  (Ftjnke,  Prog.  med. 
Wochen.,  1895,  p.  342)  an  end-to-end  anastomosis  was  made  of  ileum  into 
colon,  while   both   ends  of   the  diseased   bowel,  were   closed,  the   preexisting 


Fig.  392. — McGraw's  Elastic  Ligature  for  Lateral  Intestinal  Anastomosis. 
A  continuous  silk  suture  is  first  applied.     Above  this  the  elastic  ligature  passes  through  all  the  coats  of 
the  bowel  as  shown.     This  is  tied  so  tight  that  it  speedily  cuts  its  way  through  the  bowel,  establishing  the  anasto- 
mosis.    The  continuous  suture  is  then  carried  over  the  elastic  ligature,  completely  covering  it  in.     A  strong  silk 
ligature  is  used  to  secure  the  knot  in  the  elastic  ligature  as  shown. 


fistula  also  being  denuded  and  closed ;  but  on  the  third  day  it  was  necessary 
to  cut  the  fistula  sutures,  on  account  of  some  fever  and  discomfort,  a  measure 
resulting  in  the  escape  of  a  slimy,  fecal  fluid,  followed  by  immediate  improve- 
ment. The  occasion  for  pursuing  this  plan  of  complete  exclusion  in  7  of 
the  8  cases  cited  was:  in  one,  multiple  stenoses,  which  would  have  involved 
too  extensive  a  resection  of  the  bowel;  in  5,  the  immobility  of  the  tumor 
ami  the  danger  of  opening  paratyphlitic  abscesses ;  and  in  one,  the  wretched 


782        OPERATIVE   TREATMENT   OF   NEOPLASMS   AND   SPECIFIC   INFECTIONS. 


JT.Sutur-e    of  all   co&t& 
posterior    l^yer 


\      IF  ■Serous    sutur 

mntenor    l*yt>r 


Fig.  393. — Lateral  Anastomosis  after  Halsted. 
The  ends  of  the  bowel  have  been  inverted  by  continuous  or  mattress  sutures  and  the  lateral  approximation 
is  made  (I,  left  upper  figure).  Recently  dishing,  Roux,  and  others,  instead  of  the  interrupted  sutures  used  by 
Halsted,  have  employed  continuous  sutures  which  insure  greater  rapidity;  puckering  can  be  avoided  if  knots  are 
tied  at  intervals.  Then  the  bowel  is  incised  and  its  margins  united  by  suturing  through  all  its  coats,  as  shown 
in  II  and  III.  Lastly,  the  continuous  suture  first  applied  is  continued  so  as  to  cover  in  the  anastomotic  opening 
completely,  as  shown  in  TV.  dishing  has  demonstrated  to  bis  class  that  if  the  blind  pouches  are  left  free,  they 
may  become  intussuscepted  and  thus  close  the  opening.  To  prevent  this  contingency,  he  sutures  the  pouches 
to  the  side  of  the  intestine,  as  shown  in  the  figure. 


METHODS   OF   OPERATION    FOR   ILEOCECAL   TUMOR.  783 

general  condition  of  the  patient.  The  better  plan  of  procedure  is  to  bring  out- 
side and  leave  open  both  ends  of  the  excluded  area ;  and  if  the  patient  is  weak 
and  the  extirpation  of  the  disease  promises  to  be  too  extensive,  the  best  plan  of 
all  appears  to  be  the  simple  intestinal  anastomosis  (short-circuiting),  followed 
at  a  later  date  by  the  removal  of  the  diseased  portion,  for  complete  exclusion 
has  hardly  yet  won  for  itself  a  recognized  place  in  the  intestinal  surgery  of 
this  area. 

We  now  come  to  the  f  o  u  r  t  h  a  lternative,  namely,  the  complete 
removal  of  the  disease  associated  with  the  immediate  suturing  of  the  healthy  bowel 
above  it  to  the  healthy  colon  below  it.  Out  of  81  cases  collected  by  Conrath, 
this  method  of  treatment  was  adopted  in  48,  8  of  whom  died  from  the  operation, 
while  one  remained  unimproved  on  account  of  the  re-opening  of  a  fistula. 
The  great  sources  of  danger  from  this  operation  are :  insufficient  closure  in  the 
line  of  suturing,  resulting  in  infection  and  death  from  peritonitis  due  to  contami- 
nation of  the  peritoneum  with  abscesses,  or  with  the  foul  contents  of  the  bowel. 
The  patient  may  also  die  of  collapse,  if  the  operation  is  unduly  prolonged.  In 
one  of  the  fatal  cases  of  tuberculosis  the  ureter  was  cut  through,  and  a  nephrec- 
tomy was  performed.  The  following  methods  of  operation  were  adopted  in 
Conrath's  48  cases  of  extirpation:  In  40  the  cecum  was  extirpated  and  the 
ends  of  the  bowel  united  with  a  circular  suture;  in  3  the  bowel  was  united 
by  lateral  apposition  of  ileum  to  colon;  in  3  a  lateral  implantation  of  the  end  of 
the  ileum  into  the  side  of  the  colon  was  employed;  in  2  the  Murphy  button 
was  used ;  in  one  the  ends  of  the  bowel  were  brought  together  over  a  carrot 
cylinder. 

The  mortality  for  resection  in  cecal  tuberculosis  (16.7  per  cent.)  is  37  per 
cent,  better  than  in  resections  of  the  bowel  for  carcinoma,  and  25  per  cent, 
better  than  in  the  results  of  ileocecal  resections  in  general ;  and  Conrath  points 
out  that  since  1898,  when  WOlfler  collected  his  statistics,  an  improvement  of 
10  per  cent,  has  taken  place.  The  fate  of  30  cases,  which  Conrath  was  able  to 
follow  up  after  the  operation  for  tuberculosis,  shows  that  within  six  months  one 
died  of  hemorrhage  from  the  rectum,  one  of  hemoptysis,  one  of  a  local  recurrence 
of  the  disease,  one  of  tuberculosis  of  the  lungs,  and  one  of  a  relapse  and  the 
accompanying  marasmus.  One  patient  died  of  tuberculous  lungs  within  a 
year  after  operation;  another  within  two  years;  another  in  three;  and  still 
another  in  three  and  a  half,  of  tuberculosis  of  lungs,  intestine,  and  peritoneum. 
Out  of  30  cases,  only  16  remained  in  good  health,  one  to  seven  years  after 
operation. 

In  ileocecal  tuberculosis  it  is  important  not  only  to  excise  the  disease, 
but  to  remove  any  intimately  adherent  and  suspicious  areas  of  the  neighboring 
small  intestine  as  well.  The  method  of  end-to-end  anastomosis  is  as  follows: 
After  packing  off  the  rest  of  the  abdomen  with  the  utmost  care,  in  order  to  avoid 
any  contamination  and  the  fatal  peritonitis  which  is  almost  sure  to  follow  such 
a  misfortune,  the  affected  area  is  freed  on  all  sides,  if  fistulous  with  a  portion 


784        OPERATIVE  TREATMENT   OF   NEOPLASMS    \M>  SPECIFIC   INFECTIONS. 

of  tlic  abdominal  wall  attached,  or  with  some  of  the  densely  adherent  parietal 
peritoneum.    The  tumor  mass  is  then  brought  outside  and  laid  on  compresses, 

while  the  assistant  controls  the  bowel,  well  above  the  disease,  with  his  fingers, 


Fig.  394. — Steps  in  Connell's  Operation  fob  Intestinal  Anastomosis  by  Suture  within  the  Bowel  and 
Transfixion  of  all  the  Coats,   Including  the  Mucosa. 


or  with  a  rubber  band  transfixing  the  mesentery.  A  clamp  is  applied  close  to 
the  diseased  portion  and  the  small  intestine  is  divided  between  the  two.  The 
diseased  portion  is  then  lifted  up,  exposing  the  mesenteric  vessels  going  to  it. 
The  mesentery  is  next  cut  in  the  form  of  a  V;  including  the  entire  diseased  area. 


METHODS   OF   OPERATION   FOR   ILEOCECAL   TUMOR.  785 

Care  must  be  taken  not  to  divide  or  ligate  any  of  the  vessels  supplying  the  bowel 
beyond  the  affected  areas.  As  the  mass  is  lifted,  the  colon  is  exposed,  clamped 
next  to  the  disease,  and  controlled  by  simple  compression,  without  any  con- 
trolling force  beyond  this,  and  divided  between  the  two,  thus  completely  sever- 
ing the  diseased  portion,  which  is  then  removed.  The  exposed  mucosa  is  carefully 
cleansed,  and  the  end-to-end  anastomosis  is  then  made,  by  one  of  several  plans. 
In  event  of  haste  Murphy's  button,  which  has  found  such  wide  acceptance, 
may  be  used;  otherwise  a  deliberate  suture  which  secures  careful  union  by  two 
or  more  rows  of  fine  silk  sutures  is  always  preferable.  Tor  this  purpose  I  would 
recommend  following  one  of  two  plans.  Halsted's  method  of  using  inflata- 
ble rubber  bags,  which  serve  to  equalize  any  inequality  in  the  lumina  which 
may  exist,  is  simple  and  satisfactory.  The  bowel  ends  are  basted  together, 
as  it  were,  by  three  or  four  sutures;  the  collapsed  bag  is  then  inserted  between 
them  and  inflated.  The  accurate  apposition  of  the  ends  by  two  layers  of  mattress 
sutures,  first  sero-muscular,  and  then  sero-serous,  is  now  easily  effected.  The 
sero-serous,  which  is  protective,  may  be  made  continuous  to  save  time.  Especial 
care  must  be  taken  to  bring  the  mesenteric  border  into  snug  apposition,  as  this 
is  the  weakest  feature  of  the  operation. 

Another  most  satisfactory  plan  of  suture  is  that  employed  by  Connell  of 
Chicago.  Fine  silk  sutures  are  used,  and  all  the  suturing  is  done  on  the  inside 
of  the  bowel,  as  shown  in  the  illustrations  (see  Fig.  394).  The  mesenteric  stitch, 
applied  as  shown  at  a  a  in  the  upper  figure,  secures  snug  apposition  at  this  point, 
and  it  is  left  of  sufficient  length  to  act  with  a  second  stitch  applied  at  b  b,  about 
one-third  of  the  way  around  the  lumen,  to  hold  the  bowel  taut  and  the  edges 
together,  while  mattress  sutures  are  applied  through  all  the  coats,  as  shown  in 
the  middle  figure.  Another  gut  suture  at  c  c  (upper  figure)  serves,  together 
with  those  at  a  a  and  b  b,  to  facilitate  the  application  of  the  remaining  sutures, 
all  of  which  enter,  emerge,  and  are  tied  on  the  mucous  surface.  The  author 
himself  takes  pains  to  apply  even  the  very  last  suture  on  the  inside,  but  this  is 
unnecessary.  The  last  two  or  three  sutures  may  be  placed  through  the  serous 
and  muscular  coats  on  the  outside.  A  continuous  suture,  outside  of  the  row 
just  described,  serves  to  support  it  and  gives  an  additional  security.  A  lateral 
anastomosis  maybe  effected,  after  closure  of  the  amputated  ends,  by  McGraw's 
method  (Jour.  Amer.  Mai.  Assoc,  .May  Hi.  1891),  as  shown  and  described  in 
Fig.  392  (p.  781),  where  the  anastomosis  is  secured  after  the  operation  by  the 
cutting  of  a  tight  elastic  ligature  through  all  the  coats  of  the  bowel.  A  more 
deliberate  plan,  of  lateral  anastomosis,  is  shown  in  Fig.  393  (p.  782),  where  the 
opening  from  bowel  to  bowel  is  united  on  all  sides  by  a  continuous  silk  suture 
including  all  its  coats,  and  protected  by  a  sero-serous  suture,  surrounded  on  all 
sides  as  described  in  the  legend. 


50 


CHAPTER  XXXIV. 

HERNIA  OF  THE  APPENDIX. 

The  free  mobility  and  uncertain  length  of  the  cecum,  and  the  variations  in 
its  position  due  to  developmental  anomalies  (see  Chap.  VI),  are  such  that  the 
appendix  may  be  found  in  any  region  of  the  abdomen  and  in  close  relations 
with  the  various  abdominal  rings,  in  which  it  may,  finally,  become  engaged. 
As  a  matter  of  fact,  this  little  organ  has  been  discovered  in  (lie  inguinal  and 
femoral  canals  on  either  the  right  or  left  side,  and  also  within  the  umbilicus, 
within  the  obturator  foramen,  and  in  the  various  retrocolic  and  retrocecal  fossa'. 
The  appendix  may  be  found  in  a  hernial  sac,  cither  as  its  sole  content,  or  in  com- 
bination with  other  portions  of  the  bowel,  or  with  the  omentum.  The  earliest 
observation  of  a  hernia  of  the  appendix  is  probably  that  of  MoRGAGN]  in  1751 
(Jopsox,  Univ.  Med.  Mag.,  1900).  Another  was  soon  after  reported  by  Soem- 
mering, and  then  one  by  Morse,  who  in  1802  (Graziani,  These  de  Montpellier, 
1900)  mentioned  a  ease  of  crural  hernia  containing  the  appendix.  In  the  collec- 
tion belonging  to  the  Hunterian  .Museum  in  London  there  is  a  specimen,  accom- 
panied with  a  history  of  a  right  inguinal  hernia,  which  had  proceeded  to  abscess 
formation  and  was  finally  opened,  discharging  feculent  pus,  a  good  recovery 
following.  At  autopsy,  thirty  years  later,  the  cecum  was  found  adherent  to  the 
internal  ring  by  the  area  corresponding  to  the  site  of  the  appendix;  the  latter, 
however,  had  entirely  disappeared.  Only  isolated  examples  of  appendical 
hernia  are  to  lie  found  in  the  literature  up  to  the  time  when  the  radical  cure  of 
rupture  became  customary,  but  it  is  now  known  that  the  appendix  is  present  in 
from  1  to  2  per  cent,  of  all  hernias.  Of  101  cases  analyzed  by  Puuss  (I.  1)., 
Halle-Wittenberg,  1902),  21  per  cent,  occurred  in  children  of  two  years  and 
under;  the  relative  number  of  cases  then  diminished  until  the  fifth  decade,  when 
a  sudden  marked  increase  was  again  noticed.  The  cases  collected  by  Rivet 
(cpioted  from  Jopson)  also  showed  that  the  affection  is  more  common  in  young 
children  and  in  advanced  life  than  in  early  adult  and  middle  age.  Men  are 
affected  more  often  than  women,  the  proportion,  according  to  Rivet,  being  70 
per  cent,  in  the  former  to  30  per  cent,  in  the  latter;  while  Priiss  gives  78 and  22 
per  cent.  There  is,  however,  a  great  preponderance  of  the  femoral  variety  in 
females.  The  inguinal  form  constitutes  from  70  to  80  per  cent,  of  all  cases,  the 
femoral  20  to  30  per  cent.,  while  only  2  or  3  cases  of  umbilical  and  one  of  ob- 
turator hernia  have  been  reported.     In  Eccles'  report  of  the  cases  at  St.  Bar- 

786 


ETIOLOGY.  787 

tholomew's  Hospital  there  were  13  femoral  and  1G  inguinal  hernias  of  the 
appendix. 

The  hernia  may  be  congenital  or  acquired.  I  have  found  only  two  cases 
(Sandefort's  and  Lettau's)  in  which  the  hernia  was  observed  at  birth,  but 
if  by  congenital  hernia  is  understood  a  congenital  predisposition,  namely,  a 
patent  funicular  process,  many  of  the  cases  fall  under  this  head,  a  large  propor- 
tion occurring,  as  I  have  said,  in  infants.  Sandefort's  case  (quoted  from  Graz- 
iani,  Joe.  fit.)  was  that  of  an  infant  born  with  a  scrotal  hernia  which  did  not 
receive  any  attention  until  three  months  later,  when  a  bandage  with  pressure 
was  applied  under  the  impression  that  reduction  was  complete.  Soon  symptoms 
of  strangulation  developed  and  death  followed.  An  autopsy  showed  that  the 
hernia  was  formed  by  the  cecum,  the  termination  of  the  ileum,  and  the  vermi- 
form appendix,  the  latter  being  adherent  to  the  testicle  and  to  the  bottom  of 
the  sac,  and  on  account  of  the  hardening  of  the  appendix  it  was  judged  that 
the  adhesion  had  taken  place  during  fetal  life.  Lettau's  case  (Dtsch.  Zeit. 
/.  Chir.,  190.3,  Bd.  70,  No.  2,  p.  84)  was  an  example  of  the  umbilical  form  and 
was  mistaken  for  a  patent  .Meckel's  diverticulum.  At  operation  the  appen- 
dix was  found  to  be  the  only  content  of  the  sac.  Congenital  hernia  of  the  appen- 
dix is  generally  ascribed  to  the  formation  in  the  fetus  of  adhesions  between  the 
appendix  and  the  peritoneum  covering  the  testis  and  gubernaculum.  Rok- 
itansky,  Yirchow,  Orth,  and  others  claim  that  the  peritoneum  in  the  fetus 
is  frequently  the  seat  of  a  chronic  or  acute  inflammatory  process,  and  that  the 
resulting  adhesions  are  often  the  cause  of  anomalous  positions  of  the  abdominal 
organs.  With  few  exceptions,  in  the  cases  observed  in  children,  the  appendix 
is  adherent. 

The  principal  causes  of  the  acquired  form  are,  unusual  mobility  and 
length  of  the  cecum  and  appendix,  and.  what  amounts  to  the  same  thing, 
the  descent  of  the  colon  in  general  enteroptosis.  The  causes  usually  in  action 
in  the  causation  of  hernia  in  general,  contribute  to  produce  appendical  hernia 
as  well.  It  is  probable,  as  pointed  out  by  Pruss.  that,  in  many  cases,  the  cecum 
or  some  other  portion  of  the  bowel  enters  the  sac  with  the  appendix,  but  while  the 
former  returns  to  the  abdomen,  the  latter,  on  account  of  its  length  and  small 
diameter,  or  because  of  adhesions,  remains  in  the  sac.  The  presence  of  adhe- 
sions between  the  appendix  and  omentum  may  result  in  the  former  being  forced 
into  a  hernia  at  the  same  time  as  the  latter.  In  a  case  of  J.  M.  T.  Finney  (per- 
sonal communication)  the  sac  contained  a  large  incarcerated  omental  hernia, 
while  the  appendix  was  found  in  the  outer  posterior  portion  of  the  canal,  but 
was  entirely  extraperitoneal,  its  inner  surface  only  being  covered  with  a  reflec- 
tion of  the  sac.  The  factors  concerned  in  producing  left-sided  hernias  are, 
congenital  anomalies  in  the  position  of  the  cecum  and  appendix  :  as.  fur  instance, 
when  the  cecum  occupies  the  left  iliac  fossa  owing  to  failure  of  development 
of  the  transverse  colon,  or  in  cases  of  situs  transversus.  Again,  a  long  cecum  and 
appendix,  especially  when  associated  with  descent  of  the  colon,  may  extend 


788 


HERNIA   OP  THE   APPENDIX. 


.- 


appendix  in 
nguinal  hernia 


■ 


'vA/rtm 


Fig.  395. — Appendix,  with  the  Cecum  and  Beginning  of  Ascending  Colon  in  a  Left  Inguinal  Hernia. 
J.  H.  H.,  July  12,  1903.     Autopsy  No.  2136;  age  eighty-one. 


etiology. 


7V> 


across  from  the  right  to  the  left  side.  Deformities,  such  as  scoliosis  and  kyphosis 
may,  as  Foerstkr  claims  (Univ.  of  Pa.  Med.  Mag.,  1901),  be  etiologic  factors 
in  producing  left  appendical  hernias.  A  large  iliac  hernia  on  the  left  side  in 
old  individuals  with  lax  abdominal  walls  may  draw  the  cecum  and  appendix 
into  the  sac.  This  was  evidently  the  mechanism  of  the  case  shown  in  Fig. 
395,  which  was  observed  in  an  old  man  of  eighty-one  years  who  had  entered  the 
Johns  Hopkins  Hospital  suffering  from    general    arteriosclerosis,    and    having 


Puerperal  Uterus  beneath         \ 

sac  formed  by  elongated         1 

parietal  peritoneum   and  \i    .     g.  , 

mesentery.  \r      fc, 

AdhApp 


Ad  h.  Omentum 


<        I       C 
Fig.  396. — The  Appendix,  Cecum,  Colon*.  Small  Intestine,  and  Omentum,  Adherent  in  Umbilical  Hernia. 


a  cardiac  aneurysm.  The  abdominal  walls  were  greatly  relaxed  and  there  was 
an  easily  reducible  inguinal  hernia  on  both  sides,  the  left  being  much  the  larger. 
The  appendix  rarely  forms  the  contents  of  an  umbilical  hernia,  two  instances 
only,  so  far  as  I  know,  having  been  reported,  namely,  that  of  I.kttau,  already 
mentioned,  and  a  case  related  by  Jeaxxiel  (cited  by  Priiss).  I  have  met  with 
one  example  of  this  form  of  hernia  Csce  Fig.  396),  observed  at  autopsy  on  a 
woman  aged  twenty-five,  who  had  died  of  acute  miliary  tuberculosis  during  the 
puerperium.  Bary  (I.  D.  Greifswald)  recorded  a  fatal  case  in  which  the  appen- 
dix was  adherent  in  the  obturator  foramen. 


790 


HEHXIA    OF    THE    APPENDIX. 


The  complications  which  may  arise  are  irreducibility,  s  t  rangu- 
1  a  t  i  o  n  ,  and  i  n  f  1  a  m  m  a  t  i  o  n  .  The  irreducibility  of  the  appendix  is 
usually  the  result  of  the  adhesions  which  are  commonly  present,  hut,  as  Jopson 
remarks,  the  fact  that  the  easily  reducible  hernias  are  often  not  operated  upon 
makes  it  impossible  to  estimate  the  frequency  of  its  occurrence.  Kinking  of 
the  appendix  may  prevent  its  return  to  the  abdomen,  and  also  cystic  distention, 
as  in  the  cases  described  by  Wolfler  (Arch.  j.  klin.  Cliir.,  Bd.  121,  p.  432)  and 
Van  Hook  (Med.  and  Surg.  Rep.,  1896).     Strangulation  and  inflammation  can- 


Fig.  397. — The  Appendix  in  a  Right  Inguinal  Hernia. 
The  appendix  was  thickened  and  rigid,  but  free  from  adhesions.     Man,  age  sixty-seven. 


not  always  be  differentiated  before  operation,  and  as  strangulation  induces 
inflammation,  and  vice  versa,  it  is  often  difficult,  even  at  operation,  to  deter- 
mine which  was  of  primary  occurrence.  Chronic  or  acute  inflammation  may, 
however,  develop  without  evidence  of  strangulation.  It  is  produced  by  the 
usual  causes  of  appendicitis,  especially  trauma,  and  gives  rise  to  the  character- 
istic symptoms  of  the  affection. 

The  case  of  right  inguinal  hernia  represented  in  Fig.  397  was  that  of  a  sailor 
aged  sixty-seven,  who  had  first  noticed  the  swelling  in  the  groin  shortly  after  a  severe 


TREATMENT.  791 

strain  in  lifting.  The  hernia  was  easily  reduced  and  kept  in  place  with  a  truss,  but 
the  patient  desired  a  radical  cure  on  account  of  the  pain  experienced  when  walking 
without  the  support.  The  sac,  which  was  of  considerable  size,  was  found  empty 
except  for  the  tip  of  the  thickened,  indurated,  but  not  adherent  appendix. 

In  another  case  occurring  in  the  practice  of  my  associate,  G.  L.  Hunner,  acute 
gangrenous  appendicitis  in  a  right  femoral  hernia  developed  without  producing  any 
symptoms  of  strangulation.  The  patient,  a  woman  aged  sixty-nine,  gave  a  history 
of  attacks  of  abdominal  pain  sometimes  located  about  the  umbilicus,  at  other  times 
across  the  lower  abdomen.  Her  bowels  were  habitually  constipated.  Three  days 
before  admission  to  the  hospital  she  began  to  suffer  from  rather  severe  pain  in  the 
lower  right  abdomen  and  for  the  first  time  noticed  a  swelling  in  this  region.  There 
was  slight  fever,  but  no  nausea  nor  vomiting.  The  abdomen  was  soft  and  natural- 
looking,  except  for  the  swelling  in  the  right  lower  quadrant,  where  a  somewhat 
tender  mass  extended  a  few  centimetres  above  Poupart's  ligament  and  into  the 
groin.  The  skin  over  the  mass  was  infiltrated  and  indurated  as  well  as  slightly 
reddened.  Operation  showed  that  the  entire  appendix,  with  a  small  portion  of  the 
cecum,  was  gangrenous,  the  distal  half  forming  the  contents  of  a  femoral  hernia 
(see  Fig.  398). 

Acute  perforative  appendicitis  in  a  hernial  sac  has  frequently  been  described 
and  in  several  instances  has  been  associated  with  the  presence  of  foreign  bodies, 
and  has  sometimes  followed  traumatism.  Several  cases  have  been  described 
in  which  the  cecum  and  proximal  portion  of  the  appendix  were  contained  in 
the  sac,  while  the  tip  of  the  appendix  passed  back  into  the  abdominal  cavity. 
In  such  cases  the  tip  may  become  gangrenous  or  perforated,  while  the  part  in 
the  hernia  is  only  slightly  inflamed.  Symptoms  of  complete  obstruction  prob- 
ably reflex  in  origin  may  develop  in  cases  of  strangulated  appendical  hernia. 
As  a  rule,  the  obstruction  is  found  to  be  less  complete  than  when  other  portions 
of  the  bowel  are  involved. 

The  diagnosis  of  appendical  hernia  from  other  forms  is  seldom  possible. 
It  may  easily  be  mistaken  for  an  omental  or  a  Richter's  hernia.  Sometimes 
when  the  appendix  occupies  the  sac  alone  it  can  be  felt  as  a  cord-like  struc- 
ture. Coley  (Ann.  Surg.,  1895,  vol.  21.  p.  385)  succeeded  in  making  a  correct 
diagnosis  in  two  instances,  in  one  of  which  it  was  based  upon  the  fact  that  after 
reducing  the  hernia,  a  small  and  evidently  adherent  portion  remained.  In  the 
other  case,  the  hernia,  which  was  small,  was  easily  reduced,  but  traction  upon  the 
testis  caused  it  to  return,  thus  demonstrating  the  presence  of  adhesions. 

TREATMENT. 
Operations  for  the  relief  of  hernia  in  the  appendix  are  of  two  kinds,  namely, 
of  election  or  of  necessity.  An  operation  of  election  is  one  performed  when 
there  is  nothing  in  the  circumstances  to  make  it  urgent  and  it  is  a  matter  of 
choice  with  the  patient,  who  desires  to  get  rid  of  his  hernia,  and  decision  with 
the  surgeon,  whose  services  are  to  accomplish  this  end.     An  operation  of  neces- 


792 


HERNIA   OF  THE   APPENDIX. 


sity  is  one  urgently  demanded  on  account  of  strangulation,  or  the  supervention 
of  an  inflammatory  condition  in  the  sac. 

When  the  sac  is  opened,  the  operator  may  find  its  contents  to  consist  of  the 


Gangrenoui  dlbtal  portion 
in  femoral   nernia. 


/ 


Fig.  398. — Httnher's  Case.     Gangrenous  Appendix  i\  a  Right  Femoral  Hernia.     The  Overlying  Tis- 
sues Infiltrated  and  Acutely  Inflamed.     Woman,  age  sixty-nine. 


appendix  alone,  or  of  the  appendix  and  cecum  together,  associated,  it  may  be, 
with  more  or  less  of  the  adjacent  bowel.  If  the  appendix  and  the  associated 
bowel  are  perfectly  normal  and  free  from  adhesions,  and  if  there  have  been  no 


TREATMENT.  793 

previous  suspicious  attacks  of  pain  and  tenderness  in  the  sac,  they  may  be  re- 
turned to  the  abdominal  cavity.  In  my  judgment,  however,  it  is  better,  as  a 
general  rule,  under  such  favorable  conditions  for  exposure  and  manipulation, 
to  remove  the  appendix  by  ligating  its  mesentery,  and  then  amputating  the  organ, 
turning  it  into  the  cecum  and  suturing  the  orifice,  according  to  one  of  the  plans 
described  in  Chap.  XXV;  after  which  the  hernial  sac  is  closed  secundum  artem. 
In  grave  cases,  where  there  is  suppuration  in  the  sac.  it  must  be  drained,  and 
here,  as  well  as  in  the  cases  where  there  is  gangrene  in  the  appendix,  result- 
ing from  strangulation  (see  Fig.  398),  the  utmost  care  must  be  observed  in 
handling  the  diseased  tissues  in  order  to  avoid  inoculating  the  peritoneal  cavity. 
If  the  diseased  portion  is  found  to  extend  up  into  the  peritoneal  cavity, 
the  operator  must,  at  all  hazards,  discover  the  upper  limits  of  the  infection 
and  resect  the  bowel  in  its  healthy  portion.  Moreover,  he  must  do  this  with 
the  least  possible  manipulation  and  traction  upon  the  parts,  preferably  by 
enlarging  the  abdominal  opening  in  the  direction  of  the  canal,  while  protecting 
the  healthy  regions  and  keeping  the  disease  well  isolated  by  abundant  gauze 
compresses.  "When  the  infection  extends  still  further  up  into  the  abdomen,  an 
even  wider  incision  must  be  made,  if  necessary  in  the  form  of  an  inverted  T 
in  order  to  provide  abundant  drainage  after  removal  of  the  disease.  In  such 
cases  the  cure  of  the  hernia  becomes  a  matter  of  secondary  consideration,  to 
be  taken  up  after  recovery. 


CHAPTER   XXXV. 
MEDICO-LEGAL  ASPECTS  OF  APPENDICITIS. 

The  existence  of  a  legal  status  in  certain  cases  of  appendicitis  is  not,  as  might  be 
expected,  a  matter  of  only  recent  recognition.  As  far  hack  as  1837  Petrequin, 
in  his  well-known  article  on  the  value  of  opium  in  perforation  of  the  intestines, 
and  of  the  vermiform  appendix  in  particular  (see  Chap.  XXIII.  p.  511),  com- 
mented on  the  legal  aspects  of  such  cases  as  follows :  "  Are  not  intestinal  lesions  of 
this  kind  (spontaneous  perforation)  really  a  branch  of  legal  medicine?  Monsieur 
Alphonse  Devergie  says  that  the  study  of  spontaneous  perforations  is  of  special 
interest  to  the  medical  lawyer;  the  collection  of  symptoms  to  which  they  give 
rise  and  the  pathologic  alterations  which  follow  in  their  train  being  capable  of 
simulating  poisoning  and  occasioning  symptoms  which  attack  individual  repu- 
tations." Larret-Lamalignie,  writing  in  1862,  also  emphasizes  the  resem- 
blance between  the  symptoms  of  arsenic  poisoning  and  those  of  perforation  of  the 
appendix.  A  medical  man  studying  history,  and  reading  between  the  lines,  must 
often  feel  a  conviction  that  many  of  the  suspected  poisonings  so  common  a  few  cen- 
turies ago  were,  in  reality,  only  cases  of  acute  and  fulminating  intestinal  affec- 
tions, and  not  infrequently  of  appendicitis  and  peritonitis;  indeed,  literary  investi- 
gation along  these  lines  offers  a  field  of  interesting  conjecture  to  any  student  of 
history  gifted  with  the  necessary  insight.  A  case  of  fulminating  appendicitis 
is  not  so  likely,  to-day,  to  be  mistaken  for  one  of  acute  poisoning  in  any  well- 
organized  community,  for  the  universal  suspicion  of  the  poisoner  as  well  as  of  the 
evil  eye  is  now  a  thing  of  the  past ;  moreover,  the  symptoms  of  appendicitis  are  at 
present  so  well  understood  that  it  is  immediately  suspected  not  only  by  the 
medical  attendant,  but  often  by  the  patient  himself  or  his  friends.  Still  it  is 
possible  that  such  an  error  might  arise  and  demand  investigation,  although  the 
risk  to-day  is  rather  in  the  opposite  direction,  namely,  that  a  veritable  poisoning 
will  be  labelled  appendicitis,  and  so  escape  recognition. 

A  new  field  of  inquiry,  however,  has  appeared  since  Pethequin's  time,  arising 
from  a  long-standing  conviction  that  a  causal  relationship  exists  between  ap- 
pendicitis and  trauma,  and  may  be  a  matter  of  considerable  importance. 

The  naturally  protected  position  of  the  appendix,  lying  as  it  floes  against 
the  posterior  abdominal  walls  and  covered  by  intestines,  would  seem  at  first 
sight  to  negative  the  possibility  of  any  injury  from  a  direct  trauma,  unless 
of  the  severest  character.  There  is  abundant  evidence,  however,  to  the  contrary, 
and   the  medico-legal  complications  which  may  arise  in  cases  of  appendicitis 

794 


TRAUMATIC    APPENDICITIS.  7**0 

occasioned  by  such  common,  and  apparently  trivial  injuries  as  a  blow,  a  kick, 
a  contusion,  or  even  a  violent  strain  are  numerous  and  interesting.  From  this 
standpoint  appendicitis  becomes  of  importance  to  life  insurance  corporations 
where  there  are  limitation  clauses  in  the  policies,  as  well  as  in  benefit  associa- 
tions where  insurance  is  guaranteed  for  bodily  injury  but  excluded  in  spontaneous 
internal  disease,  or  when,  on  the  contrary,  the  patient  Is  insured  against  ordin- 
ary ailments,  but  not  against  accident. 

It  has  already  been  noted  (see  Chap.  XVI)  that  the  number  of  cases  in  which 
appendicitis  is  associated  with  injury  or  violence  is  much  greater  than  is  generally 
credited,  and  it  follows  that  the  desire  to  establish  the  connection  between 
appendicitis  and  trauma  should  receive  greater  attention  in  the  future.  It  is  a 
curious  fact  that  patients  are  prone  to  account  for  tumors,  notably  of  the  breast 
or  in  the  abdomen,  by  a  fall,  a  bruise,  or  a  strain;  but  in  acute  abdominal 
affections,  beginning  with  colic,  the  attention  is  turned  at  the  outset  in  an  entirely 
different  direction,  and  an  indiscretion  in  diet  or  an  exposure  to  cold  is  the  first 
thought  in  seeking  an  explanation  of  the  malady.  In  this  field,  therefore,  the  sur- 
geon will  do  well  not  to  depend  upon  the  spontaneous  suggestion  of  the  patient  as 
to  injury  or  violent  exertion  preceding  the  attack  of  appendicitis ;  he  must,  in  each 
instance,  seek  to  elucidate  an  immediate  provoking  cause  by  careful,  well-directed 
questioning.  If,  however,  the  case  has  any  possible  medico-legal  bearing,  the 
medical  attendant  must  be  guarded  in  his  inquiries  so  as  not  to  suggest  or  insinuate 
that  a  trauma  is  the  directly  responsible  agent  in  producing  the  malady. 

My  personal  interest  in  trauma  as  a  cause  of  appendicitis  was  first  aroused  by 
an  incident  occurring  some  twenty  years  ago,  and  I  believe  I  cannot  better  illus- 
trate the  change  of  attitude  undergone  by  the  profession  relative  to  the  subject 
during  this  period  than  by  briefly  citing  the  facts  and  instituting  a  comparison 
between  the  case  and  a  similar  one  recently  brought  to  my  notice. 

During  my  residence  at  the  Episcopal  Hospital  in  Philadelphia,  in  the  year 
1882-1883,  a  boy  of  about  ten  years  old,  was  brought  into  the  children's  ward 
suffering  from  an  attack  of  peritonitis  with  much  pain  and  fever;  his  abdomen 
was  tumid,  and  he  was  evidently  very  ill.  He  stated  that  he  had  been  struck 
in  the  abdomen  by  another  boy,  and  the  illness  had  followed  promptly  upon  the 
injury.  The  boy  who  inflicted  it  was  being  held  by  the  police  until  the  upshot 
of  the  case  should  be  known.  The  little  patient  died,  and  the  autopsy  revealed 
a  perforation  of  the  appendix  by  a  coprolith,  with  a  consequent  suppurative 
peritonitis.  At  this  date,  three  or  four  years  before  Fitz's  article  had  laid  the 
foundations  of  knowledge,  our  understanding  of  such  cases  was  still  most  imper- 
fect, and  at  the  inquest  I  asserted  with  a  clear  conscience  that  there  was  no  de- 
monstrable connection  between  the  lesion  in  the  appendix  (the  manifest  cause  of 
death)  and  the  blow  which  had  preceded  it;  it  seemed  to  be  a  clear  case  of  post 
hoc  and  not  jirnpter  hoc,  and  the  boy  in  custody  was,  therefore,  at  once  released. 
Had  I  been  called  upon  to  testify  some  years  later  under  the  same  conditions, 
my  opinion  would  have  been  more  guardedly  expressed. 


796  MEDICOLEGAL    ASPECTS  OF   APPENDICITIS. 

The  second  ease,  which  I  wish  to  contrast  with  this  one,  occurred  in  Baltimore 
twenty  years  later,  and  was  reported  in  one  of  the  daily  papers  (Baltimore  Daily 
Sun,  July  28  and  29,  1902).  A  hoy,  twelve  years  old,  died  at  St.  Joseph's 
Hospital,  alter  an  operation  for  appendicitis,  immediately  following  a  blow  upon 
the  abdomen,  struck  by  a  companion,  during  a  quarrel.  The  assailant  was  ar- 
rested on  the  charge  of  assault,  and  then  released,  hut  on  the  death  of  the  patient 
he  was  re-arrested  to  await  the  verdict  of  the  coroner's  jury.  The  city  physician 
X.  (!.  KEIRLE,  testified  that  "the  autopsy  showed  inflammation  of  the  appendix 
which  hail  given  rise  to  appendicitis.  The  appendicitis  could  have  been  occasioned 
by  a  blow."  There  was  no  foreign  body  in  the  appendix.  The  verdict  of  the  cor- 
oner's jury  was:  "  We  find  that  death  was  caused  by  appendicitis  and  peritonitis, 
but  we  are  unable  to  say  in  what  manner  said  appendicitis  was  caused."  The 
prisoner  was,  therefore,  released.  It  will  be  xom  that  in  the  twenty  years  be- 
tween my  first  experience  and  this  case,  professional  opinion  had  so  far  advanced 
that  the  possibility  of  a  traumatic  origin  for  the  appendicitis  was  readily 
admitted,  although  not  considered  sufficiently  established  to  justify  an  unfav- 
orable verdict.  It  is  but  natural  that  only  the  most  positive  proof  should 
influence  a  jury  to  find  the  defendant  guilty  under  such  circumstances. 

\Y.  B.  Small,  of  Lewiston,  Maine,  writing  upon  the  relation  of  trauma  to 
appendicitis  (.V.  Y.  Med.  Rec,  1S9S,  vol.  54,  364),  says:  "I  believe  the  true 
cause  of  the  greater  percentage  of  appendicitis  in  young  men  is  found  in  the  more 
frequent  exposure  to  accidental  injuries  and  strains,  and  to  the  strong  contrac- 
tions of  the  abdominal  muscles  necessary  in  their  work This  ex- 
planation brings  the  subject  into  prominence  from  a  medico-legal  point  of  view. 
Some  cases  show  plainly  the  direct  results  of  external  violence,  and  I  believe 
accident  insurance  companies  or  corporations,  and  individuals  responsible  for 
the  occurrence  of  accidents,  are  as  plainly  liable  as  for  a  broken  limb."  This 
opinion  accords  with  my  own.  Small,  six  years  ago.  was  able  to  collect  15  cases 
of  appendicitis  occasioned  by  trauma,  from  the  literature  and  from  individual 
reports;  now,  six  years  later,  I  find  50  with  but  little  effort.  I  present  these  as 
illustrative  without  comment,  in  the  form  of  brief  abstracts,  with  the  original 
reference  in  every  instance. 

1.  Goldbeck.  I.  D.  Wurms,  1830.  A  boy.  ten  years  old,  fell  from  the  top 
of  a  hay-wagon,  and  eight  days  later  began  to  have  pain  in  the  right  iliac  fossa,  with 
the  usual  symptoms  of  appendicitis,  increasing  in  severity  until  death.  At  the 
autopsy  the  appendix  was  found  gangrenous  and  perforated;  its  tip  contained  a 
fecal  concretion. 

2.  G.  Southam.  Lancet.  1840,  vol.  2,  p.  565.  A  man,  twenty  years  old,  a 
weaver  by  trade,  received  a  severe  blow  from  his  beam,  which  swung  round  and 
struck  him  in  the  abdomen.  Slight  pain,  generally  distributed  over  the  abdomen, 
began  shortly  after  the  injury  was  received,  and  persisted  for  six  months,  although 
it  was  not  severe  enough  to  prevent  the  patient's  working  for  some  time;  at  the 
end  of  half  a  year,  however,  it  increased  in  severity  and  became  localized  in  the  right 


TRAUMATIC    APPENDICITIS.  797 

iliac  fossa.  A  year  after  the  accident,  when  the  patient  was  admitted  to  the  hos- 
pital, he  had  a  swelling  in  the  right  groin,  which  burst  and  discharged  externally 
at  the  navel.  Death  occurred  .sixteen  months  after  the  receipt  of  the  injury;  the 
autopsy  showed  an  appendix  bent  upwards,  and  adherent  to  the  anterior  abdomi- 
nal wall  at  a  point  within  an  inch  of  the  umbilicus,  with  which  it  was  connected 
by  a  short  fistulous  tract.  The  appendix  was  thickened  and  dilated,  with  the  shell 
of  a  large  hazelnut  impacted  in  it. 

3.  Hartshornk.  Trans.  Coll.  Phys.  Phila.,  1853.  p.  86.  A  girl,  fourteen  years 
old.  became  exhausted  by  skipping  rope  backwards  forty  times  in  succession, 
making  a  revolution  of  the  rope  for  herself  each  time.  Immediately  after  she 
felt  a  tearing  pain  in  the  bowels,  accompanied  by  nausea  and  faintness,  but  these 
symptoms  soon  passed  away.  Eight  or  ten  days  later,  however,  she  was  seized 
with  the  same  symptoms  while  at  school,  and  when  seen  by  Habtshorne  on  the 
fifth  day  of  her  illness  she  was  in  extremis.  The  autopsy  showed  a  perforation  of 
the  appendix  with  a  fecal  concretion  just  above  the  opening,  and  still  within  the 
appendix. 

4.  O.  Ward.  Trans.  Path.  Soc.  Land..  1856,  vol.  13,  p.  210.  A  boy,  thirteen 
years  old,  was  kicked  on  the  right  side  of  the  abdomen.  Symptoms  of  appendic- 
itis showed  themselves  within  a  week,  and  a  physician  was  summoned.  Death 
took  place  on  the  eighth  day,  and  the  autopsy  showed  a  perforated  appendix  con- 
taining a  fecal  concretion. 

5.  (!.  T.  Elliot.  Amer.  Mai.  Mouth..  1S58,  vol.  10,  p.  359.  A  boy,  eleven 
years  old.  received  a  blow  on  the  abdomen  from  a  playmate  severe  enough  to  ren- 
der  him  breathless  for  a  moment.  Soon  afterwards  he  ate  his  dinner,  and  at  once 
began  to  have  pain  in  the  abdomen.  A  physician  was  called  twenty-four  hours 
later,  and  the  patient  died  on  the  twenty-fourth  day  after  the  injury  was  received. 
At  the  autopsy  the  appendix  was  found  perforated,  and  bound  to  the  cecum  by 
adhesions.     There  is  no  mention  of  a  concretion. 

6.  L.  Down.  Trans.  Path.  Soc.  Loud..  1867,  p.  97.  A  man,  thirty  years  old, 
had  had  one  attack  of  pain  in  the  right  iliac  fossa  with  vomiting.  A  year  later,  after 
dancing  at  a  party,  he  was  again  seized  with  pain  in  the  abdomen,  which  was  soon 
relieved,  and  a  physician,  sent  for  on  the  fourth  day,  found  him  apparently  recover- 
ing. On  the  ninth  day,  however,  after  a  sudden  movement  in  bed.  the  pain  returned 
with  symptoms  of  collapse,  and  he  died  the  same  evening.  The  autopsy  showed 
an  appendix  bound  down  to  the  omentum  by  adhesions;  it  was  perforated,  and  con- 
tained two  small  fecal  masses. 

8.  R.  H.  Parker.  Brit.  Med.  Jour..  1872.  vol.  2.  p.  526.  A  bow  seven  years 
old.  was  struck  on  the  abdomen  by  some  iron  railings.  Shortly  afterwards  he  was 
attacked  by  nausea  and  vomiting,  and  the  next  day  by  pain  in  the  abdomen  with 
tenderness  on  pressure.  On  the  third  day  he  was  taken  to  a  hospital,  and  died  on 
the  sixth.  At  the  autopsy  the  appendix  was  found  perforated,  and  near  to  it,  in 
the  right  iliac  fossa,  lay  a  fecal  concretion. 

9.  C.  D.  Homaxs.  Bost.  Mid.  and  Sura.  Jour.,  1873,  vol.  88.  p.  45.  A  girl,  seven 
years  old,  fell  for  a  distance  of  eight  or  ten  feet.  The  day  afterwards  she  began  to 
have  severe  pain  in  the  abdomen,  most  marked  on  the  right  side,  and  a  physician 
was  sent  for,  who  pronounced  her  to  have  appendicitis;   on  the  fifth  day  she  died. 


798  MEDICO-LEGAL    ASPECTS  OF  APPENDICITIS. 

The  autopsy  showed  that  the  appendix  was  perforated  and  contained  a  fecal  con- 
cretion. 

12.  W.  M.  Campbell.  Med.  and  Ckir.  Reporter,  Liverpool,  1885,  vol.  10,  p.  26. 
A  boy,  nine  years  old,  received  a  severe  blow  on  the  abdomen,  and  a  week  after- 
wards he  was  seized  with  paroxysms  of  abdominal  pain.  A  physician  was  called 
as  soon  as  the  pain  began,  but  the  child  died  on  the  fourth  day.  At  the  autopsy 
the  appendix  was  found  much  dilated,  and  adherent  to  the  umbilicus.  No  men- 
tion is  made  of  perforation,  or  of  a  concretion. 

11.  T.  <!.  Morton.  Jour.  Amcr.  Med.  Assoc,  June  16.  1891.  A  young  girl, 
age  not  given,  had  a  severe  fall  on  the  buttocks,  immediately  followed  by  nausea 
and  vomiting,  lasting  for  hours.  These  symptoms  passed  off  after  a  time,  hut  re- 
turned occasionally,  after  fatigue,  during  eighteen  months;  she  then  had  an  attack 
of  pain  in  the  right  iliac  fossa  followed  by  others  of  the  same  kind.  Four  years 
after  the  injury  she  had  a  violent  attack  of  such  pain,  accompanied  by  symptoms 
of  a  high  degree  of  inflammation,  and  on  operation  the  appendix  was  found  per- 
forated and  firmly  adherent  to  the  cecum.  Search  was  made  for  a  foreign  body, 
but  none  was  found. 

12.  IuiD.  Trans.  Coll.  Phys.  Pliilo.,  1S90.  A  boy.  eleven  years  old.  subject 
for  two  or  three  years  to  attacks  of  "colic"  in  the  right  iliac  fossa,  was  struck 
in  the  right  side  of  the  abdomen  with  the  handle  of  a  spade,  while  at  play.  This 
injury  was  followed  immediately  by  intense  pain,  but  he  was  not  confined  to  bed 
until  the  next  day.  An  operation,  performed  on  the  fifth  day.  showed  the  appen- 
dix perforated  and  glued  to  the  cecum;  there  was  a  small  fecal  concretion  in  the 
perforation. 

13.  N.  Bridge.  Med.  News,  May  24.  1S90.  A  boy,  fourteen  years  old,  pre- 
viously strong  and  active,  was  out  hunting  all  day,  and  became  excessively  fatigued. 
On  his  return  he  felt  badly,  and  on  the  third  day  had  diarrhea,  with  pain  and  ten- 
derness in  the  cecal  region.  A  physician  was  sent  for  on  the  fifth  day,  but,  until 
the  eighth,  the  symptoms  continued  mild;  there  was  then  a  violent  attack  of  pain 
with  vomiting,  and  death  ensued  soon  after.  At  autopsy  the  appendix  was  found 
perforated.     There  is  no  note  of  a  fecal  concretion. 

14.  H.  0.  Marcy.  Bost.  Med.  and  Surg.  Jour..  1891,  vol.  124.  p.  524.  A  man, 
twenty-nine  years  old,  was  exposed  to  a  severe  strain  while  operating  on  the  cadaver, 
and  felt  something  give  way;  immediately  afterwards  he  had  an  attack  of  appendic- 
itis. About  six  months  later  he  had  a  second  attack,  followed  by  others  to  the 
number  of  eight  during  the  next  six  months.  On  operation,  in  the  quiescent  period 
after  the  ninth  attack,  the  appendix  was  found  shorter  and  wider  than  usual.  It 
did  not  contain  a  concretion,  and  was  not  adherent,  but  there  were  numerous  ad- 
hesions running  from  the  head  of  the  cecum. 

15.  Ferret.  Lyon  med.,  1.892,  torn.  70.  p.  279.  A  girl,  seven  years  old,  had  a 
fall  on  the  right  side,  followed  by  severe  pain  in  the  right  iliac  fossa.  From  this 
she  recovered,  but  a  second  attack  occurred  in  two  months,  and  a  year  later  she 
was  seized  with  pain  in  the  right  groin,  with  other  symptoms  of  appendicitis.  At 
operation  the  appendix  was  found  red,  swollen,  and  perforated.  There  is  no  men- 
tion of  a  concretion. 

16.  T.  W.  Kf.lyxack.     Pathology  of  Appendicitis.  1893,  p.  99.      A  boy.  fifteen 


TRAUMATIC    APPENDICITIS.  799 

years  old,  was  forcibly  seized,  hung  up  by  the  legs,  head  downward,  over  a  man's 
back,  and  violently  shaken.  A  short  time  afterward  symptoms  of  appendicitis 
appeared,  mild  at  first  but  increasing  in  severity  until  the  end  of  a  week,  when  he 
was  seen  by  a  physician  and  sent  to  a  hospital.  The  abdomen  was  opened  and 
washed  out.  but  the  patient  died  in  a  few  hours.  At  the  autopsy  the  appendix 
proved  larger  than  normal,  was  acutely  flexed  on  itself,  gangrenous,  and  perforated; 
it  contained  nodules  of  hardened  feces. 

17.  G.  R.  Fowler.  Appendicitis,  1894.  p.  127.  A  man.  age  not  given,  felt 
severe  pain  in  the  right  iliac  fossa  while  lifting  a  heavy  cake  of  ice.  The  pain  con- 
tinued, but  was  not  severe  enough  to  confine  the  patient  to  bed.  On  operation  the 
appendix  was  found  gangrenous  and  perforated;   it  contained  a  fecal  concretion. 

18.  H.  P.  Hawkins.  Diseases  of  the  Vermiform  Appendix,  1895.  p.  96.  A 
boy.  sixteen  years  old,  was  lifting  some  heavy  baggage  when  he  felt  a  severe  pain  in 
the  right  side  of  the  abdomen,  followed  by  the  usual  symptoms  of  appendicitis. 
These  decreased,  and  for  a  time  he  improved,  but  in  the  third  week  of  his  illness  he 
had  a  severe  recurrence,  and  was  sent  to  a  hospital,  where  he  died.  At  the  autopsy 
it  was  found  that  the  tip  of  the  appendix  had  sloughed  off;  there  is  no  mention  of 
a  fecal  concretion. 

19.  Gordon.  These  de  Paris,  1S96.  A  girl,  six  years  old,  was  kicked  in  the 
upper  right  side  of  the  abdomen.  About  twelve  hours  after  the  injury  she  was 
attacked  by  vomiting,  accompanied  by  black  stools,  and  was  then  taken  to  a  hos- 
pital, where,  on  the  fourth  day,  severe  abdominal  pain  began  with  other  symptoms 
of  appendicitis  shortly  followed  by  death.  The  autopsy  showed  a  perforated  ap- 
pendix; there  is  no  mention  of  a  fecal  concretion. 

20.  Ibid.  A  girl,  nine  years  old.  was  struck  on  the  abdomen  by  one  of  her 
companions  with  the  fist.  The  clay  after  the  injury  the  patient  began  to  have  pain 
in  the  right  iliac  fossa,  and  was  taken  to  the  hospital  three  days  later,  where  she 
soon  afterwards  died  At  the  autopsy  the  appendix  was  found  perforated  at  its 
free  extremity    with  a  small  concretion  situated  near  the  perforation. 

21.  Ibid.  A  boy.  nine  years  old,  was  playing  with  a  companion,  who  jumped 
suddenly  on  his  back  and  upset  him.  A  violent  pain  in  the  right  iliac  fossa  felt  at 
the  time  of  injury  soon  disappeared,  but  returned  a  few  hours  later,  with  all  the 
symptoms  of  appendicitis.  He  was  then  taken  to  a  hospital,  where,  on  operation, 
the  appendix  was  found  bent  upon  itself,  and  adherent  by  its  tip  to  the  omentum. 
It  was  not  perforated,  nor  is  there  any  mention  of  a  concretion. 

22.  D.  C.  Moriata.  .V.  Y.Med.  Jour.,  1S96,  p.  546.  A  boy,  fourteen  years 
old,  was  kicked  in  the  abdomen  by  a  playmate,  and  a  few  days  later  he  devel- 
oped symptoms  of  appendicitis,  when  a  physician  was  summoned.  On  operation 
the  appendix  was  found  swollen  and  perforated:  it  contained  a  common  pin,  which 
the  child  stated  he  had  swallowed  about  a  year  before.     The  case  ended  fatally. 

23.  Delorme.  Bull,  it  mem.  <h  hi  Soc.  d<  chir.  de  Paris.  1S97,  torn.  22.  p.  543. 
A  man.  age  not  given,  was  kicked  by  a  horse  in  the  region  of  the  umbilicus,  and 
immediately  became  ill  with  appendicitis,  from  which  he  died  on  the  third  day. 
The  autopsy  revealed  a  perforated  appendix  with  a  concretion  lying  in  the  perfora- 
tion. 

24.  H.  Mynter.     Appendicitis,  1897,  p.  225.     A  youth,  nineteen  years  old.  in 


800  MEDICOLEGAL    ASPECTS  OF  APPENDICITIS. 

previous  good  health,  received  a  blow  in  the  abdomen,  not  instantly  followed  by 
bad  effects.  A  few  honrs  later,  however,  he  began  to  have  pain  in  the  right  iliac 
fossa,  soon  followed  by  other  symptoms  of  appendicitis.  A  physician  was  sent  for 
the  next  day,  and  at  operation,  on  the  third  day  from  the  injury,  the  appendix  was 
found  perforated;  it  contained  two  fecal  concretions,  in  the  middle  of  one  of  which 
was  a  foreign  body. 

25.  W.  B.  Small.  N.  Y.  Med.  Rec,  1898,  vol.  54,  p.  364.  A  boy,  nine  years 
old,  spent  some  time  in  pushing  a  heavy  dump-cart  with  its  tongue  resting  against 
his  abdomen.  Within  twenty-four  hours  he  was  taken  ill  with  appendicitis,  and 
a  physician  was  sent  for.  On  operation  the  appendix  was  found  to  have  sloughed 
away;   there  is  no  mention  of  a  concretion. 

20.  Iuit).  (Jrom  F.  L.  Dixon).  A  man,  thirty  years  old,  jumped  from  a  small 
island  to  the  mainland,  and  in  the  act  he  felt  a  pain  in  the  right  iliac  fossa,  so  sharp 
as  to  force  him  to  lie  down  at  once.  The  pain  lasted  several  days,  and  then  dis- 
appeared. Three  or  four  similar  attacks  preceded  his  final  illness,  in  which  he 
received  no  medical  aid  until  near  the  end.  On  operation,  numerous  old  adhesions 
were  found,  but  no  concretion  is  mentioned;   he  died  a  few  hours  later. 

27.  [bid.  (Jrom  V.  L.  Dixon).  A  man,  twenty-seven  years  old,  fell  through  a 
trap-door,  for  a  distance  of  seven  or  eight  feet,  into  a  cellar.  He  complained  at 
once  of  injury  in  the  right  side,  but  did  not  feel  ill  enough  to  send  for  a  physician 
until  the  end  of  two  weeks.  On  operation  the  appendix  was  found  gangrenous, 
and  it  contained  two  enteroliths. 

28.  E.  M.  Pond.  N.  Y.  Med.  Rcc,  April  23,  1898.  A  boy,  twelve  years  old, 
rccched  a  blow  on  the  abdomen,  whose  exact  character  is  not  stated.  For  two 
weeks  afterwards  he  had  some  digestive  symptoms  and  pain  in  the  right  iliac  fossa; 
at  the  end  of  that  time,  while  at  a  circus,  he  was  suddenly  taken  ill  with  severe  ab- 
dominal pain  and  vomiting,  and  two  days  later  he  was  seen  by  a  physician.  A 
diagnosis  of  appendicitis  was  made,  and  on  operation  the  appendix  proved  perfo- 
rated ;  it  contained  a  fecal  concretion. 

29.  A.  P.  Gould.  Lancet,  1898,  vol.  1,  p.  10.  A  man,  twenty-four  years  old, 
who  had  always  been  robust,  took  an  unusually  long  bicycle  ride,  after  which  he 
felt  sick.  Thirty-six  hours  later  he  began  to  suffer  with  pain  in  the  right  iliac  fossa; 
and  on  the  fourth  day  after  the  ride  a  physician  was  sent  for.  On  operation  for 
appendicitis  the  appendix  was  found  perforated  in  four  places,  and  it  contained 
three  fecal  concretions. 

30.  M.  Neumann.  Langen.  Arch.  /.  klin.  Chir.,  1900,  vol.  02,  p.  408.  A  boy, 
ten  years  old,  in  previous  good  health,  ran  against  the  tongue  of  a  wagon,  striking 
his  abdomen  with  such  force  against  it  that  he  fell  to  the  ground.  The  pain  shortly 
afterwards  increased  so  much  that  he  was  forced  to  go  to  bed.  after  which  it  spread 
through  the  whole  abdomen,  and  was  accompanied  by  vomiting,  until,  on  the  third 
daw  he  was  taken  to  a  hospital.  Examination  showed  a  distended  abdomen,  quick- 
ened breathing,  a  rectal  temperature  of  38.5°  C,  and  dvdness  on  the  right  side. 
Puncture  let  out  a  gray,  stinking  fluid;  and  a  posterior  incision,  made  on  the  fifth 
day,  opened  a  foul  abscess  and  exposed  a  thickened,  gangrenous  appendix.  Death 
occurred  on  the  seventh  day,  of  fibrinous  peritonitis,  and  at  the  autopsy  a  con- 
cretion was  found  in  a  necrotic  appendix. 


TRAUMATIC   APPENDICITIS.  801 

31.  Ihid.  A  boy,  seven  years  old,  was  kicked  twice  in  the  abdomen  by  another 
boy,  immediately  after  which  he  suffered  great  pain  and  went  to  bed.  During  the 
night  he  vomited,  and  next  day  was  much  worse.  On  the  second  day  he  entered 
a  hospital,  where  examination  showed  a  distended  abdomen  and  pain,  most  severe 
on  the  right  side.  At  operation,  on  the  third  day,  a  peritonitis  was  found,  caused 
by  a  red,  thickened,  perforated  appendix,  the  mucous  lining  of  which  was  gan- 
grenous over  a  zone  1.5  cm.  in  breadth,  while,  corresponding  to  the  perforation,  there 
was  a  grayish-yellow,  firm,  oval  calculus  as  large  as  an  orange-seed.  Death  took 
place  two  days  later. 

32.  Ibid.  A  boy,  fourteen  years  old,  received  a  blow  on  the  abdomen,  the 
source  of  which  is  not  stated,  and  developed  symptoms  of  peritonitis  on  the  same 
day,  although  he  was  not  seen  by  a  physician  until  the  fourth.  At  operation  the 
appendix  was  found  perforated,  and  it  contained  a  fecal  concretion. 

33.  Ibid.  A  boy,  nine  years  old,  in  previous  good  health,  was  jumping  in  some 
athletic  exercises,  when  he  suddenly  felt  a  severe  pain  in  the  right  side  of  the  abdo- 
men. The  day  afterwards  he  was  obliged  to  return  from  school  on  account  of  severe 
pain,  which  increased  for  two  days,  and  on  the  third  he  entered  a  hospital.  On 
operation  the  appendix  was  found  perforated  and  it  contained  a  small  concretion. 

34.  Ibid.  A  man,  twenty-nine  years  old,  whose  health  had  always  been  good, 
was  lifting  a  heavy  weight  when  he  suddenly  felt  a  severe  pain  in  the  abdomen, 
which  steadily  increased.  A  physician  was  sent  for  next  clay,  and  the  patient  taken 
to  a  hospital  the  day  afterwards.  On  operation  the  appendix  was  found  perforated 
and  a  concretion  was  lying  in  the  perforation.  Three  more  concretions  were  found 
at  the  autopsy. 

35.  Ibid.  A  man  twenty  years  old,  whose  health  had  always  been  good, 
although  he  had  once  spent  a  few  days  in  a  hospital  on  account  of  bruises  due  to 
a  kick  from  a  horse,  began  to  have  pain  in  the  right  iliac  fossa  shortly  after  lifting  a 
heavy  sack.  The  next  day  he  was  better,  but  shortly  afterwards  the  pain  became 
severe.  On  the  ninth  day  after  the  injury  he  was  admitted  to  a  hospital,  where  an 
operation  showed  that  nothing  was  left  of  the  appendix  except  a  thickened  stump, 
1.5  cm.  long;  a  concretion  the  size  of  a  hazelnut  was  lying  in  the  abdominal  cavity. 

36.  Ibid.  A  man,  thirty-two  years  old,  in  previous  good  health  except  for 
rheumatism,  was  thrown  down  by  a  large  hog  and  trampled  upon  over  the  abdomen. 
Immediately  after  the  injury  he  was  taken  to  a  hospital.  ( )n  operation,  the  appen- 
dix proved  to  be  perforated,  and  a  concretion  lay  just  outside  the  perforation. 

37.  Ibid.  A  boy,  twelve  years  old,  in  previous  good  health,  received  a  blow 
on  the  abdomen,  and  shortly  afterwards  began  to  have  pain  in  the  right  iliac 
fossa,  which  confined  him  to  bed  and  required  opium  for  its  relief.  On  the  tenth 
day  he  entered  the  hospital,  where,  on  operation,  the  appendix  could  not  be  dis- 
covered, but,  when  the  dressings  were  changed,  a  fecal  concretion  was  found  in 
the  wound. 

38.  Ibid.  A  man,  forty-one  years  old,  whose  health  had  always  been  good, 
took  a  long  ride  on  his  bicycle,  and  five  hours  afterwards  began  to  have  pain  in  the 
right  iliac  fossa.  On  the  third  day  after  the  pain  began,  he  entered  a  hospital,  with 
all  the  symptoms  of  a  diffuse  peritonitis.  On  operation,  the  appendix  was  found 
perforated,  and  it  contained  a  fecal  concretion. 

51 


802  MEDICO-LEGAL    ASPECTS   OF   APPENDICITIS. 

39.  [bid.  A  man,  twenty-six  years  old,  whose  health  had  always  been  good, 
was  lifting  a  heavy  weigb.1  when  lie  suddenly  fell  a  severe  pain  in  the  righl  iliac  fossa, 
followed  immediately  by  other  symptoms  of  appendicitis.  He  was  seen  at  once  by 
a  physician  and  sent  to  a  hospital  on  the  third  day  after  the  pain  began.  On  opera- 
tion, the  appendix  was  found  just  about  to  perforate;  it  contained  a  fecal  concre- 
tion. 

■K).  [bid.  A  boy,  sixteen  years  old,  in  previous  good  health,  was  seized  with 
severe  pain  in  the  abdomen  while  lifting  a  heavy  sack  of  potatoes.  The  morning 
after  the  injury  he  was  taken  very  ill  with  symptoms  of  appendicitis,  which  con- 
tinued to  grow  worse,  until  the  fifth  day,  when  he  was  admitted  to  the  hospital  in 
extremis.  At  the  autopsy  the  appendix  was  found  perforated;  it  contained  a  con- 
cretion the  size  of  a  cherry-stone. 

41.  A.  J.  OCHSNEK.  Month.  Jour.  Mid.  and  Sun/.,  Louisville,  Feb.,  1900. 
A  girl,  ago  not  stated,  received  a  blow  on  the  abdomen  from  a  heavy  hoard  which 
swung  round  rapidly  and  struck  her.  Immediately  after  the  injury  she  began  to 
have  pain,  which  persisted  fortwo  years,  when  she  had  an  attack  of  acute  appendic- 
itis. On  operation,  the  appendix  was  found  inflamed,  but  not  perforated;  no 
mention  is  made  of  a  concretion. 

42.  Du  Barry.  This,  d,  Paris,  1901.  A  child,  ten  years  old,  fell,  striking 
the  abdomen  against  the  handle-bar  of  a  bicycle.  Immediately  after  the  accident, 
genera]  abdominal  pain  began,  which  became  localized  within  two  days,  and  shortly 
afterwards  subsided;  it  returned,  however,  eight  months  later.  A  physician  was 
sent  for  on  the  ninth  day  of  the  second  attack.  On  operation,  the  appendix  was 
found  inflamed,  but  not  perforated;    there  is  no  mention  of  a  concretion. 

43.  E.  W.  Sharp.  Brit.  Med.  Jour.,  1902,  p.  1519.  A  man,  nineteen  years 
old,  in  previous  good  health,  was  working  in  a  coal-mine,  where  he  sustained  a  .severe 
crush,  involving  the  abdomen,  between  two  coal-wagons.  At  the  time  of  the  acci- 
dent there  was  not  much  suffering,  but  about  a  month  later  the  patient  complained 
of  pain  and  tenderness  in  the  right  iliac  fossa,  which  confined  him  to  bed  for  a  short 
time.  Five  months  later  he  had  another  attack,  and  at  the  end  of  three  weeks  he 
entered  a  hospital  in  extremis.  Autopsy  showed  an  ileus  with  a  subacute  inflam- 
mation of  the  appendix  (see  p.  805). 

44.  ('.  1».  Lockwood.  Appendicitis,  its  Pathology  and  Surgery,  1901,  p.  93.  A 
man,  twenty-two  years  old.  was  seized  with  abdominal  pain  after  dancing,  followed  by 
other  symptoms  of  appendicitis,  which  became  steadily  worse.  A  physician  was 
sent  for  mi  the  second  day,  and  on  operation  the  appendix  was  found  perforated; 
it  contained  a  fecal  concretion. 

45.  T.  S.  Cullen.  N.  Y.  Mid.  Jour..  1902,  vol.  7G,  p.  1111.  A  boy,  fourteen 
years  old,  had  a  severe  fall,  followed  by  pain  in  the  right  iliac  region,  lasting 
eight  weeks.  Some  time  after  recovery  he  went  on  a  fishing  excursion,  where  he 
was  exposed  to  much  cold  and  fatigue,  and  the  next  day  he  had  severe  pain  over 
the  appendix.  This  continued  for  ten  days,  when  operation  showed  the  appendix 
inflamed,  but  not  perforated;  there  is  no  mention  of  a  fecal  concretion.  (See  Fig-;. 
348  and  349,  pp.  665  and  666.) 

40.  B.  McMonagle.  Personal  communication,  1902.  A  man,  twenty-two  years 
old,  had  been  rowing  for  exercise,  immediately  after  which  he  felt  pain  in  the  right 


TRAUMATIC    APPENDICITIS.  803 

iliac  fossa,  accompanied  by  severe  bladder  symptoms,  and  sent  at  once  for  a  phy- 
sician. He  recovered  from  this  attack,  but  a  year  later  he  had  another  in  which 
an  abscess  was  opened,  without,  however,  restoring  him  to  health.  At  a  second 
operation  the  appendix  was  found  inflamed  and  adherent  to  the  bladder;  there  is  no 
mention  of  a  concretion. 

47.  A.  E.  Malloch.  Personal  communication,  1902.  A  young  man,  age  not  given, 
was  lifting  a  heavy  cheese  from  a  shelf,  while  standing  upon  a  step-ladder,  and  as 
the  ladder  shifted  to  one  side,  he  suddenly  strained  violently  to  keep  himself  from 
falling.  Pain  in  the  side  began  immediately,  and  kept  him  in  bed,  more  or  less, 
for  three  days.  On  the  tenth  day  he  was  seized  with  symptoms  of  perforation  and 
died  on  the  eleventh.  The  postmortem  showed  a  ruptured  abscess  sac,  containing 
a  hard,  pencil-like  piece  of  feces,  a  sharp,  bristle-like  substance,  and  the  sphacelated 
appendix    (see  fuller  account,  p.  808). 

48.  J.  H.  H.,  Surg.  No.  14451.  A  man,  twenty  years  old.  was  run  over  when 
he  was  twelve  years  of  age,  by  a  wagon,  which  passed  over  the  lower  part  of  the  ab- 
domen. He  had,  ever  since,  had  occasional  attacks  of  ''colic,"  with  a  tendency  to 
swelling  in  the  abdomen.  Just  before  he  was  seen  he  had  a  severe  attack,  brought 
on  by  excessive  fatigue.  He  was  operated  upon  in  the  quiescent  period  after  this 
illness.  The  appendix  was  subacutely  inflamed,  and  adherent  to  the  under  side 
of  the  cecum.     There  is  no  mention  of  a  concretion. 

49.  J.  H.  H.,  Surg.  No.  12477.  A  man,  forty-four  years  of  age,  was  lifting  a 
heavy  fertilizer  when  he  felt  a  sharp  pain  in  the  side  of  the  abdomen,  which  was 
relieved  for  the  time,  but  returned  next  day  accompanied  by  symptoms  of  appendic- 
itis. He  entered  the  hospital  five  days  alter  the  injury,  and  on  operation  the  appen- 
dix was  found  sloughed  off  from  its  base;   it  contained  a  concretion  in  its  tip. 

50.  J.  H.  H.,  Surg.  No.  1591.  A  man,  twenty-four  years  old,  experienced  a  sud- 
den pain  in  the  right  iliac  fossa,  while  playing  foot-ball,  so  severe  as  to  oblige  him 
to  go  home  to  bed,  where  he  was  ill  for  two  weeks.  About  eight  years  later  he  had 
a  second  attack,  after  which  they  occurred  repeatedly.  He  was  operated  on  in  the 
quiescent  period  after  the  last  attack,  and  the  appendix  was  found  bent  upon  itself 
at  a  sharp  angle.     There  is  no  mention  of  a  concretion. 

I  have  analyzed  this  series  of  cases,  keeping  in  view  the  following  points: 
Age;  Sex;  Previous  health;  Nature,  locality,  and 
severity  of  the  injury;  Evidence  of  external  vio- 
lence ;  Length  of  time  elapsing  between  the  in  j  u  r y 
a  n  (1  the  first  s  y  in  p  t  o  in  s  o  f  a  p  p  e  n  d  i  c  i  t  i  s  ;  S  e  v  e  r  i  t  y 
of  illness;  Evidence  of  any  previous  morbid  con- 
dition of  the  appendix;  and  1  present  here  my  analysis  in  tab- 
ular form. 


804  MEDICO-LEGAL    ASPECTS   OF   APPENDICITIS. 

ANALYSIS  OF  50  CASES  OF  APPENDICITIS  ASSOCIATED  WITH  TRAUMA, 
AND,  PRESUMPTIVELY,  OF  TRAUMATIC  ORIGIN. 

Sex. 

Male   41  cases 

Female  8      " 

Ni  it  mentioned 1   case     (child) 

Ace. 

5  to    9  rears  old,  inclusive 11  < 

10  to  14  ' 13  " 

15   "  19      "        "          -        5  " 

211    "  29      "        "           "         11  " 

30    '•  39      "         "           "         3  " 

40    "  49       •         "           "         2  " 

Not  mentioned  5  " 

Previous  Health. 

Noted  as  good  13  cases 

Previous  attacks    2      " 

Not  mentioned 35      " 

Nature  and  Locality  of  Injury. 

Blows   24  cases 

Falls     6      " 

Exertion    20      " 

Evidences  of  External  Violence,  such  as  Contusion  or  Laceration. 
Not  noted  in  any  instance. 

Length  of  Time  After  Injury  Before  Definite  Symptoms  of  Appendicitis 

Appeared. 

Immediately    24  cases 

Few  hours 13      " 

One  to  two  days   5      " 

Two  to  three  days 2      " 

One  week 1   case 

One  to  two  weeks 1      " 

Two  weeks 1      " 

One  month   1      " 

Two  years  1      " 

Not  mentioned 1      " 

Severity  of  Illness. 

Severe  at  outset    26  cases 

Mild       "      "          12      " 

Severe  symptoms  followed  by  interval  and  recurrence  ...  12      " 

Evidences  of  Previous  Morbid  Conditions  in  the  Appendix. 

Foreign  body  in  appendix   30  cases 

Adhesions    7      " 

Flexion 1  case 

Size  abnormal  1 

Cystic  1      " 

Not  noted   10  cases 


ANALYSIS    OF   TRAUMATIC   APPENDICITIS.  805 

Age  and  Sex. — A  large  proportion  of  these  traumatic  case-  (29  in  50)  occurred 
between  the  ages  of  five  and  twenty,  as  we  would  naturally  expect,  owing  to  the 
greater  liability  of  the  young  to  such  mild  accidents  as  Mows  and  falls,  and  to  the 
more  exposed  condition  of  the  appendix  in  childhood,  where  it  is  covered  only 
by  the  tender,  thin  abdominal  walls.  The  fact  that  there  are  41  males  to  s 
females  (the  sex  in  one  case  is  not  stated)  accords  well  with  the  marked  difference 
in  the  sexes  in  their  habits  of  life. 

Previous  Health. — In  most  of  the  cases  I  have  collected,  the  previous 
health  is  not  noted,  except  where  it  is  stated  as  good.  In  this  respect  the  results 
of  my  analysis  have  not  substantiated  my  expectations,  for  I  had  anticipated 
finding  that  a  trauma  would  often  prove  to  be  the  exciting  cause  of  a  recurrent 
attack  of  appendicitis.  In  only  two  cases  in  my  collection,  however,  is  there 
any  record  of  a  preceding  attack.  Further  investigation  would,  perhaps, 
bring  other  cases  to  light. 

Evidences  of  External  Violence. — My  statistics  do  not  furnish  a  single 
record  of  any  marks  of  violence  on  the  surface  of  the  body,  such  as  contusions. 

abrasions,  or  effusion  of  1>1 1  and  discoloration  of  the  skin.     I  believe,  however. 

that  here  too  the  fact  has  not  been  considered  of  sufficient  consequence  to  note, 
and  that  more  careful  examinations  in  the  future,  and  more  detailed  reports 
will  show  that,  in  many  cases,  the  blow  left  some  mark  on  the  surface,  if  only  a 
slight  one. 

Nature  and  Locality  of  the  Injury. — The  character  of  the  injury  is  of  three 
kinds :  blows,  falls,  or  muscular  exertion.  The  b  1  o  w  s  are 
either  kicks,  or  violent  impacts  with  the  fist,  given  in  the  course  of  quarrels.  ( 
1(1,  in  which  a  little  girl,  six  years  old,  was  kicked  in  the  abdomen  by  a  boy,  is  a 
typical  example  of  this  class.  Case  43  is  of  somewhat  different  character,  being 
a  contusion  of  the  deep  viscera  by  forcible  impact  due  to  a  crushing  force  rather 
than  a  blow.  A  youth  of  nineteen,  working  in  a  coal-mine,  was  caught  and 
squeezed  in  the  abdomen  between  two  coal-wagons;  symptoms  of  appendicitis 
appeared  a  month  later,  followed  by  obstruction,  and  after  repeatedly  improving 
and  then  relapsing,  the  patient  died  at  the  end  of  six  months.  The  autopsy 
showed  a  constriction  of  the  end  of  the  ileum,  from  a  fibrous  hand  about  two  and 
a  half  inches  long,  passing  from  the  end  of  the  appendix  to  the  mesentery. 
There  were  signs  of  subacute  inflammation  above  the  appendix,  at  the  distal 
end  of  which  was  a  cyst.  It  will  he  noted  that  in  all  cases  the  injuries  were  in- 
flicted by  blunt  instruments,  and  therefore  liable  to  injure  the  parts  for  a  distance 
around  the  appendix  as  well  as  the  organ  itself.  In  such  cases  the  important 
question  to  be  determined  is  whether  there  i<  an  increased  vulnerability  of 
the  appendix,  owing  to  previous  disease  or  to  the  presence  of  a  foreign  body  in 
the  form  of  a  concretion. 

The  traumata  coming  under  the  head  of  falls  are  of  two  kinds:  those  in 
which  the  patient  in  falling  strikes  himself  violently  against  the  region 
of  the  appendix,  in  which  case  the  injury  is.  of  course,  due  both  to  a  blow  and 


806  MEDICO-LEGAL    ASPECTS  OF   APPENDICITIS. 

a  fall;  and  those  in  which  there  is  no  violent  impact  in  the  neighborhood 
of  the  appendix,  bul  the  shock  /»/■  se,  or  the  sudden  translation  of  the  vis- 
cera, followed  by  instant  arrest,  results  in  the  tearing  of  some  attachment,  or  of 
adhesions.  Case  11,  in  which  appendicitis  followed  a  fall  upon  the  buttocks, 
is  a  good  illustration  of  this  cla<s.  The  numerous  cases  which  follow  <in  violent 
or  prolonged  exertion  are  also,  perhaps,  examples  (if  trauma  in  a  somewhat  differ- 
ent sense,  and  I  here  enumerate  the  various  sorts  of  strain  and  fatigue  noted  in 
my  collected  cases  in  order  to  show  the  variety  of  forms  under  which  this  partic- 
ular kind  of  trauma  may  occur.  Skipping  rope  backwards  forty  times,  mak- 
ing a  revolution  of  the  rope  each  time;  dancing  (two  cases);  violent  shaking 
of  the  body  with  the  head  downward;  long  hunting,  over-exertion  and  fatigue; 
lifting  heavy  weights  (2  cases);  unusually  long  bicycle  ride  (2  cases);  jumping 
(2  cases) ;  rowing;  playing  foot-hall :  severe  strain  while  operating. 

The  trauma  in  these  cases  cannot  depend  upon  any  blow  or  impact  upon  the 
appendix,  for  it  is  inconceivable  that  the  soft,  surrounding  structures  should  he 
capable  of  inflicting  such  injury.  We  are,  then,  limited  to  the  inference  that 
tile  exertion  has  been  the  direct  cause  of  the  injury  by  rupture  of  adhesions;  or, 
as  in  the  case  of  the  boy  hung  up  by  the  heels,  of  rupture  of  the  anatomic  attach- 
ments of  the  appendix;  or  that  a  foreign  body  lying  in  the  appendix  has  shifted 
its  position  so  as  to  bring  on  an  attack. 

Length  of  Time  Elapsing  Between  Receipt  of  Injury  and  Development 
of  Appendicitis. — In  the  large  majority  of  cases  pain  was  complained  of  imme- 
diately or  else  within  a  few  hours.  It  is  noticeable  that  whenever  an  interval  of 
weeks  or  months  elapsed  between  the  accident  and  the  well-defined  symptoms 
of  appendicitis,  there  were  more  or  less  well-marked  symptoms  of  continuous 
digestive  disturbance,  or,  on  the  other  hand,  there  was  a  history  of  repeated 
attacks  following  the  injury  and  before  the  patient  came  under  observation  for 
appendicitis. 

Severity  of  Illness. — Somewhat  more  than  half  the  cases  were  severe  at 
the  outset  and  continued  so  without  intermission;  in  about  2.">  per  cent,  the 
initial  attack  was  followed  by  an  interval  of  relief,  while  in  the  remainder  the 
symptoms  were  mild  in  the  beginning  and  gradually  increased  in  severity. 

Evidences  of  Previous  Morbid  Conditions  in  the  Appendix. — The  question 
whether  the  appendix  was  normal  at  the  time  of  the  injury  which  resulted  in 
appendicitis  is  of  considerable  importance,  for,  if  the  appendix  was  diseased  and 
therefore  liable  to  an  outbreak  of  inflammation  under  slight  provocation,  the 
status  of  the  defendant  in  a  lawsuit  is  manifestly  altered  by  the  fact.  I  am 
indebted  to  .Mr.  II.  M.  Biu'xt:  for  the  following  extract  bearing  upon  the  sub- 
ject from  the  American  and  English  Encyclopedia  of  Law  (second  edition,  vol. 
7,  article  "  Contributor y  Negligence"). 

A  g  g  r  a  v  a  t  i  o  n  of  I  n  j  u  r  y  b  y  Plaintiff's  N  e  g  1  i  g  e  n  c  e  . — 
While  the  negligence  of  the  injured  person  contributing  proximately  to  bis  injury 


TRAUMATIC   APPENDICITIS.  807 

will  bar  his  recovery  of  damages,  it  is  held  that  when  he  is  guilty  of  no  negligence 
contributing  to  the  injury,  negligence  upon  his  part  after  the  injury,  by  which  it  is 
aggravated,  will  not  prevent  him  from  recovering  damages  fur  so  much  of  the  injury 
as  the  original  wrong-doer  caused  by  his  negligence.  In  such  cases  it  seems  that 
the  damages  may  be  apportioned  or  allowance  made  by  the  jury  fur  that  portion 
of  the  injury  due  to  the  plaintiff's  fault. 

Injury  Enhanced  by  Disease. —  1.  Defendant's  negligence  causing 
or  aggravating  disease.  In  cases  where  the  defendant's  negligence  caused  a  dis- 
ease, developed  a  latent  tendency  to  disease,  aggravated  a  prior  disease,  or  led 
in  immediate  sequence  to  disease,  the  defendant  must  respond  in  damage  for  such 
part  of  the  diseased  condition  as  his  negligence  caused.  And  if  there  can  lie  no 
apportionment,  or  if  it  cannot  be  said  that  the  disease  would  have  existed  apart 
from  the  injury  inflicted  by  the  defendant,  then  the  defendant  is  responsible  for 
the  diseased  condition. 

2.  Diseased  condition  independent  of  injury — -Defendant's  knowledge. — But 
when  the  diseased  condition  exists  independently  of  the  injury,  and  does  not  flow 
from  it  as  a  natural  consequence  following  in  direct  sequence,  the  defendant's  liabil- 
ity is  only  for  such  consequences  as,  independently  of  the  diseased  condition,  were 
directly  and  immediately  caused  by  his  negligence.  Yet  if  he  knew  of  the  diseased 
condition,  and  could  have  foreseen  that  it  would  aggravate  an  injury  inflicted  by 
his  negligence,  he  is  liable  for  the  entire  consequences  that  flow  from  the  combina- 
tion of  his  negligence  with  the  existing  diseased  condition. 

In  40  out  of  my  50  collected  cases  the  appendix  deviated  in  some  way  or 
other  from  normal,  and  30  out  of  the  40  abnormal  appendices  were  noted  as  con- 
taining concretions;  in  7  of  the  remaining  10.  which  were  without  a  concretion, 
there  was  evidence  of  old  adhesions;  of  the  last  3,  1  was  Hexed  on  itself:  1  was 
cystic ;  and  1  was  unusually  short  and  wide.  No  case  has  as  yet  appeared  in  which 
it  lias  been  shown  that  an  injury  ab  externa  has  produced  an  appendicitis  in  a  pre- 
viously normal  appendix,  the  presence  of  a  foreign  body  being  taken  as  indicative 
of  disease,  since  it  is  the  consensus  of  the  educated  medical  profession  that  an 
appendix  containing  a  fecal  concretion  is  abnormal,  although  it  is  true  that  such 
an  appendix  may  remain  quiescent  for  an  indefinite  period.  We  may.  therefore, 
conclude  from  the  reported  eases  that  a  patient  who  is  carrying  a  concretion  in 
his  appendix  is  far  more  liable  to  an  attack  of  appendicitis  from  a  blow  of  suffi- 
cient force  when  suitably  directed  than  he  would  be  were  the  appendix  in  all  re- 
spects normal.  In  such  a  case  there  can  be  no  allegation  of  negligence  on  the  part 
of  the  plaintiff  in  bringing  about  or  aggravating  his  condition,  since  lie  must  have 
been  entirely  ignorant  of  it  until  it  was  revealed  by  the  surgeon's  knife.  On 
the  other  hand,  it  cannot  be  said  that  the  disease  would  have  existed  apart 
from  the  injury  inflicted  by  the  defendant,  who  becomes,  therefore,  liable  for 
the  lighting  up  of  the  disease  into  activity,  and  is  responsible  under  the  clause 
"developed  a  latent  tendency  to  disease,  aggravated  a  prior  disease,  or  led  in 
immediate  sequence  to  disease,"  as  above  quoted. 

In  order  to  determine  the  degree  of  responsibility  of  the  defendant  it  will  be 


SOS  MEDICOLEGAL    ASPECTS   UT   APPENDICITIS. 

necessary  to  ascertain  how  much  violence  was  used,  and  to  associate  this  factor 
with  the  previous  condition  of  the  appendix,  as  seen  at  operation  or  postmortem, 
according  to  the  statement  made  by  the  physician.  In  view  of  the  grave  conse- 
quences to  the  defendant  involved  in  an  action  for  damages,  the  physician  who 
examines  the  appendix  and  neighboring  structures  in  such  a  case  ought  to  note 
carefully  the  presence  or  absence  of  any  old  adhesions  (evidences  of  previous 
attacks),  of  peritonitis,  of  rupture,  of  perforation,  or  of  acute  strangulation  of 
the  appendix.  The  appendix  itself  should  be  most  carefully  preserved,  and 
preferably  in  formalin  or  in  Kaiserling  fluid,  in  order  to  demonstrate  any  ulcers 
of  the  mucous  surface,  any  old  scars,  or  strictures.  If  the  appendix  shows  signs 
of  old  disease,  if  ii  contains  a  large  concretion,  or  if  the  patient  had  had  pre- 
vious attacks  and  it  can  be  shown  that  hut  slight  force  was  used,  and  that  with- 
out intent  of  injury,  the  status  of  the  defendant  will  lie  different  from  what  it 
would  he  in  a  case  of  disease,  or  one  in  which  much  violence  was  used. 

The  question  of  trauma  as  it  affects  the  liability  of  life  insurance  companies 
becomes  somewhat  different,  since  the  injury  giving  rise  to  appendicitis  in  these 
cases  is  due  to  exertion  on  the  part  of  the  patient  himself,  rather  than  to  force 
in  the  hands  of  another.  In  the  absence  of  a  specific  exception  in  the  policy, 
the  company  ought  to  own  its  liability  for  appendicitis,  as  for  any  other  internal 
disease.  The  only  instance  in  which  such  a  company  could  escape  liability 
would  lie  where  it  could  show  that  the  plaintiff  had  knowledge  of  previous  attacks 
or  weakness,  which  lie  concealed,  or  failed  to  state  in  applying  for  his  insurance, 
and  which  information,  under  the  terms  of  his  policy,  he  was  bound  to  furnish. 

in  the  case  of  accident  insurance,  the  company  should  he  held  liable  when 
the  appendicitis  sets  in  directly  after  a  blow  or  a  strain. 

Medico-legal  Complications. — As  an  instance  of  legal  complications  re- 
lating to  an  appendicitis,  I  cite  the  following  case  (No.  -il),  tor  which  I  am 
indebted  to  A.  E.  MALLOCH,  of  Ontario,  Canada: 

A  young  man  was  attempting  to  lift  a  heavy  cheese  down  from  a  shelf,  while 
standing  on  a  step-ladder,  and  the  added  weighl  causing  the  ladder  to  shift  its  posi- 
tion, forced  him  to  exert  himself,  and  occasioned  a  violent  strain  of  tin'  abdominal 
muscles;  he  remarked  at  once  t<>  those  present  that  he  had  strained  himself  seriously. 
He  began  to  have  pain  in  his  side  almost  immediately,  severe  enough  to  keep  him 
in  bed.  more  or  less,  for  three  days,  after  which  he  improved.  On  the  tenth  day, 
however,  he  was  seized  with  symptoms  of  collapse,  and  died  the  day  afterward. 
The  postmortem  examination  made  by  Malloch  "showed  general  purulent  peri- 
tonitis with  a  ruptured  ah  containing  a  hard,  sloughing  appendix  "  (see  lis;. 
399).  The  patient,  having  taken  out  an  accident  policy  in  the  Commercial  Travel- 
ler's Insurance  Company,  the  family  presented  a  claim,  which  the  company  refused 
to  pay,  because  there  was  no  external  lesion  discoverable.  On  receiving  a  letter. 
however,  signed  by  Dk.  Mn.i.ix.  the  physician  in  charge,  as  well  as  by  Drs. 
Mali. mi  u  and  Olmstead,  who  attended  in  consultation,  testifying  as  follows,  they 
paid  the  claim:    "The  deceased  immediately  after  lifting  the  weight  stated  that 


TRAUMATIC    APPENDICITIS. 


809 


he  had  been  hurt,  and  subsequent]}'  repeated  this  to  all  whom  he  saw.  As  symp- 
toms which  were  located  in  the  region  of  the  appendix  followed  immediately,  we 
have  no  doubt  that  the  appendix  was  injured  at  the  time,  and  that  this  must  be 
considered  of  the  nature  of  an  accident." 


Fig.  399. — Case  of  A.  E.  Malloch,  Hamilton,  Ont.,  in  which  Acute  Appendicitis  and  Death  followed 

Severe  Muscular  Strain. 


In  concluding  the  subject  of  trauma,  1  would  emphasize  the  following  points: 
Evidence  is  lacking  to  show  that  trauma  has  caused  appendicitis  in  a  pre- 
viously sound  appendix. 

An  appendix  containing  a  fecal  concretion  or  other  foreign  body  is  not  sound, 
and  in  such  a  case  a  severe  muscular  strain  or  blow  upon  the  right  side  of  the 
abdomen  may  produce  a  lesion  of  the  mucous  or  muscular  coats  sufficient  to 


810  MEDICO-LEGAL    ASPECTS  OF   APPENDICITIS. 

favor  the  invasion  of  pathogenic  organisms, giving  rise  to  an  attack  of  appendic- 
itis in  nowise  differing  from  the  common  forms  of  the  disease. 

[f  the  patient  strains,  or  makes  active  use  of  the  abdominal  muscles  at  the 
time  of  the  receipt  of  the  blow,  these  factors  may  act  conjointly  in  causing  the 

attack. 

The  more  violent  the  blow  or  the  greater  the  strain,  the  greater  is  the  like- 
lihood of  an  injury  to  the  appendix. 

A  blow  acts  more  efficiently  upon  a  person  with  a  shallow  or  a  scaphoid  abdo- 
men where  the  walls  are  thin,  than  upon  one  who  is  stout  or  strongly  built. 

The  blow  acts  as  the  immediate  cause  in  producing  the  attack,  which,  while 
it  might  have  occurred  soon  without  such  intervention,  might  also  not  have 
occurred  for  some  years;    the  mediate  cause  is  usually  a  foreign  body. 

Whenever  a  physician  is  called  to  a  case  the  history  of  which  is  suggestive 
of  traumatic  origin,  he  will  do  well  to  make  careful  notes  at  the  time,  quoting  as 
far  as  possible  the  patient's  own  language  and  expressions  relating  to  the  follow- 
ing facts: 

1.  The  nature  of  the  injury,  whether  a  blow,  a  fall,  or  a  strain. 

2.  The  agent  producing  the  injury. 

3.  The  exact  point  and  manner  of  impact,  and  whether  the  patient  was  en- 
gaged in  active  exertion  or  straining  himself  at  the  time  the  injury  was  received. 

4.  The  expressions  used  by  the  patient  at  time  and  the  the  nature  of  his  imme- 
diate complaints. 

5.  The  length  of  time  elapsing  between  the  injury  and  the  call  for  medical  aid. 
0.  Any  external  evidence  of  violence  (to  be  noted  most  carefully). 

7.  If  an  interval  of  some  weeks  lias  elapsed,  an  inquiry  into  the  condition  of 
the  patient  during  this  period  should  be  made,  it  being  stated  whether  he  was 
able  to  resume  his  ordinary  occupations,  and  with  or  without  distress. 

S.  If  death  ensues  or  an  operation  is  performed,  it  is  of  the  highest  impor- 
tance to  record  the  exact  condition  of  the  peritoneum  and  the  viscera  underlying 
the  injured  area,  a  minute  and  careful  statement  regarding  the  presence  or  ab- 
sence of  fecal  concretions  being  always  recorded. 

The  following  case,  in  which  a  concealed  trauma  ami  infection  were  suspected, 
is  of  great  medico-legal  interest.  It  was  reported  by  II.  M.  BlGGS  to  the  New 
York  Pathological  Society  as  an  instance  of  suspected  criminal  abortion  which 
proved  to  be  appendicitis. 

The  patient,  an  unmarried  servant,  was  suddenly  seized  with  severe  pain  dur- 
ing a  menstrual  period.  The  attending  physician  discovered  a  general  peritonitis, 
and  associating  this  fact  with  the  occurrence  of  an  excessive  menstrual  How.  and 
"some  evidence  of  a  circumstantial  character,"  concluded  that  the  case  was  one 
of  criminal  abortion,  and  so  reported  it  to  the  Board  of  Health.  The  woman 
died,  and  the  autopsy  revealed  a  general  peritonitis  resulting  from  a  perforation 
<>f  the  appendix  about  one  and  a  half  inches  from  its  base;  a  small,  hard  mass  of 
fecal  matter  was  found  in  the  peritoneal  cavity. 


DUTY   OF   PHYSICIAN    IN   TRAUMATIC   CASES.  811 

I  hope  that  enough  has  been  said  to  convince  my  professional  colleagues 
that  appendicitis  mast  always  be  regarded  as  an  affection  for  which  an  active 
human  agency  can  be  responsible,  and  that  testimony  to  that  effect  must  be 
given,  when  the  facts  warrant  it,  with  assurance,  whether  it  be  for  or  against  an 
individual  or  an  association. 

It  is  the  duty  of  every  physician,  in  taking  the  history  of  all  cases  of  appendic- 
itis, to  inquire  carefully  into  antecedent  blows,  falls,  or  unusual  exertion,  and  to 
listen  with  attention  to  any  suggestion  made  by  the  patient  which  points  in 
that  direction.  He  must  also  bear  in  mind  that  the  injury  need  not,  necessarily, 
be  of  recent  date,  although  some  symptoms,  it  may  be  of  a  vague  character,  will 
probably  be  recalled  as  immediately  following  it. 


INDEX  OF  NAMES. 


Aarestrop,  37. 
Abbe,  367,  382,  719. 
Abrahams,  729. 
Achaud,  255. 
Ackermann,  475. 
Adami,  245. 
Adrian,  357,  379,  383. 
Aireton,  377. 
Albers,  14. 
Allen,  458. 
Ammentorp,  344. 
Anderson,  208. 
Appuhn,  319,  320. 
Arbore-Rally,  375,  454. 
Archibald,  627. 
Aretjeus,  31. 
Ashby,  243,  366. 
Ashton,  374. 
Aufrecht,  207. 
Auguy,  334. 


Baker,  366. 

Ballin,  682. 

Balzer,  403. 

Bardeleben,  105. 

Barnard,  429,  460. 

Barnsby,   104,  700,  703,  712. 

Barth.  277. 

Baruch,  46. 

Bary.  789. 

Battle,  529,  534,  535,  537,  538. 

Bayet,  404. 

Bayliss,  193. 

Beaussenat,  379,  380. 

Beck,  298,  303,  357,  358,  489,  560,  561. 

Becquerel,  375. 

Beyer,  747.  74s.  751.  755. 

Bell,  362,  363,  366,  372,  376,  37S. 

Benoit,  341. 

Berard.  333,  627,  630,  631. 

Berkley,   1S7,  188. 

Bernard.  419. 

Bernays,  420,  627,  757,  758,  759,  77:;. 


Berry,  89,  92,  132,  135. 

Berthelin,  226. 

Beskett.  373. 

Betz,  450,  454. 

BierhofT,  149,  292. 

Biggs,  36,  810. 

Bishop.  477. 

Blackadder,  6,  375. 

Blake,  J.  A.,  215. 

Blake,  J.  B.,  587. 

Blake,  J.  D.,  136,  137.  580. 

Bloodgood,  360,  377,  455,  624,  739. 

Bios,  3S9. 

Bode,  653. 

Bohr,  450. 

Boije,  732. 

Boland,  441. 

Boody,  249,  250. 

Borchardt,  227. 

Bornhaupt,  502. 

Bossard,  434. 

Bouness,  323. 

Box,  444. 

Brewer,  423,  426,  668,  670. 

Brewster,  52. 

Bridge,  798. 

Briggs,  359. 

Bright,   14,   15. 

Broca,  A.,  255,  410,  627. 

Broca,  P.,  365. 

Bredel,  55. 

Brook-.  371. 

Brotske,  91. 

Brower,  375,  376. 

Brown,  L.,  428. 

Brown,  T.  R.,  517. 

Browne,  207. 

Brucke,  672. 

Brun.  376 

Brune,  806. 

Bryant.  136.  137 

Buchner,  306. 

Buckler.  399. 

Buhl,  226,  432. 


138,  148,  250,  376,  3S6,  594. 


813 


81  I 


INDEX   OF   NAMES. 


Bull,  26,  36. 
Bunting,  749. 
Burchard,  38. 
Burge,  '■'< > 
Burnam,  744,  756. 
Bunie,  Hi.  17.  302,  120. 
Burrell,  664. 
Bvrd,  39. 


Ca 52,  684. 

Campbell,  798 
Canali,  770. 

Ca ii,  77. 

Carmalt,  501,  570. 
Carson,  739 
Caussade,  341. 
Caven,  367. 
Cayley,  215. 
Chaffey,   177. 
Charrier,  341. 
Chastenat,  380. 

Cham  ran.   2.11. 

Chevalier,  628. 

Chiari,  770. 

Christian,  349,   136. 

Christoffers,  :ns. 

Church,  243 

Churton,  739. 

Clado,  60,  63,  92,  94,  98,  104,  148,  184,  255. 

Clark,  372. 

Colin.    775. 

Cohnheim,  071'. 

Coleman,  203,  374. 

Coley,  692,  701. 

Colman,   171. 

Colmer,  367. 

Colquehoun,  -'27. 

Condamin,   121,  722. 

Connell,  784,  785. 

Connor,  468. 

Conrath,  774,  77s,  781,  783. 

Copland,   I  I. 

Cordier,  504. 

Cornil,  336. 

Cottam,  ooo. 

Councilman,  246. 

Crile,  277.  315,  364 

Crowder,  338,  312.  702.  763,  773. 

Crowell,   130. 

Crozet,  743. 

Crutcher,  73:?. 

Cruveilhier,  202 

Cullen,  207.  200.  271,  270,  308,  574,  630,  664, 

665,  7lo.  702,  763,  802. 
Cummin,   I'1-' 


Cuneo,   104,  185. 
Cunningham,  352. 
Curschmann,   111.   143,   111. 
Curtis,   '210. 
Cushing,   E.,   15s. 
Cushing,  II..  387,   lis,  518. 
Czerny,  343,   105,  771. 


Da  Cosi  v.   H9,   129 
Daland,  368. 

I  lair,   2i:..   227. 

Dance,  lo. 
Dandridge,  584. 
1  laske,  770. 
Davaine,  375. 
David,  us. 

Haul  .an... 11.  369,  563,  101. 

Deaver,52,  138,255,302,367,  no.  128,566,567 

De  la  Carriere,  450. 

Delageniere,  7 Hi. 

Delanglade,  031. 

Delbet,  652. 

Delorme,  202,  700. 

I  In  i  in  a-.    154. 

Dp  Ruyter,  750. 

De  Vecchi,  18,   132. 

Dieulafoy,  198,  227,  3m  i.  385,  391 .  104,670,671. 

Dock,  138. 

Dodwell,  761. 

Doughty,  502,  61 1.  616,  017,  670. 

Down,  615. 

Downes,  568,  -172. 

1  Iraper,  7  17 

In,  Barry,  802 

Duckworth,  52,  002. 

Dudley,  220. 

Duhrssen,  375. 

Dupallier,  375. 

Dupuytren,   10,   11,  25. 

Durand,   104. 

Durande,  774. 

Durkee,  203. 


Eastman,  571,  572. 

1  iberth-Schimmelbusch,  072. 

Eccles,  786. 

Edebohls,  2.  51,  35s,  17  1,  520,  538,  565,  566. 

Ehrich,  315. 

Einhorn,  211,  227,  358. 

Elliot,  707. 

Elsberg,  215,  222.  225.  636,  638,  030. 

Eisner,    112. 

Elting,  711.  717,  750,  751.  752,  753,  773. 


INDKX    OF   NAMES. 


815 


Emmet,  720. 
Enderlen,  477. 
Erdman,  375,  377. 
Erving,  70S,  769. 
Escherich,  258. 
Evans,  651,  652. 
Eve,  460. 
Ewald,  287. 


Faber,  375. 

Fabre,  322. 

Fawcett,  137. 

Federmann,  390. 

Fenger,   208,   322.    417.    454.    455.    487,    589, 

590,  591,  755,  764, 
Fenwick,  27,  28,  39,  714,  761. 
Ferguson,  136,   138,  249. 
Ferry,   104,  334. 
Field,  426. 
Finder,  429. 
Finkelstein,  249. 
Finney,  91,  122,  208,  271.  331,  359,  381,  382, 

392,  406,  452,  503,  505,  506,  534,  558,  559. 

561.  582,  .".sii.  602,  635,  647,  658,  697,  720, 

721,  767,  776,  787. 
Fitz,  28,  29,  30,  42,  43,  47,  149,  227,  292,315, 

358,  362,  410,  442,  481,  795. 
Foerster,  789. 
Follis,  44S,  582,  585,  626. 
Fowler,  48,  51,  204,  270,  277,  40S,  529,  531, 

561,  562,  563,  644,  674,  715,  722,  799. 
Franke,  382. 

Prankel,  243,  254,  201.  730,  732,  733,  734,  735. 
Frazier,  370. 
Freeman,  ('.   A.,  207. 
Freeman,  R.  D.,  458. 
Freind,  204. 
Fruitnight,  456. 
Funke,   781. 
Futeher,  354. 


Gaertneh,  261. 
Gaffky,  261. 
Gage,  138,  ooi.  077,  692. 
Galipe,  300. 
Gallant.   029.   714. 
Galton,  oni. 
Gardner,  374. 
Garreau,  429. 
Gaston,  38,  215. 
(lav.  33,  385,  3s7. 
( legenbauer,  79, 
( ienser,  454. 
Genzmer,   13,   14,  454. 


i  lerhardt,  072.  074 

Gerlach,  116. 

I  ierster,  330,  417,  755. 

Gibbon,  331. 

Gibney,  450,    17v  479. 

Gilford,  757. 

Giordano,  422,  423. 

Girard,  379. 

Glazebrook,  747. 

Gloniger,  453,  732. 

Goldbeck,   12,  13,  17,  796. 

Golubof,  381. 

Qoodall,  419. 

G [fellow,  374. 

Gordon,  452,  4S0,  4S7,  491,  799. 

Gosset,  244. 

Goulay,  30,  37. 

Gould,  800. 

Grant,  381. 

Grauer,  136. 

Graven,  511. 

Grawitz,  318,  323. 

Graziani,  786,  787. 

Griffith,  450, 453, 460, 461, 469. 

Grisolle,   17. 

Groin',  63,  80,  153,  349. 

Guebler,  490. 

Gussenbauer,  672. 


Haesler,  468,  469. 

Haldane,  471,  472. 

Hall,  43,  44. 

Hall.'.  319. 

Hallowell,   18. 

Hal-led,  378.  504,  559,  560,  587,  621,  635,  679, 

691,  7M',.  747.  7."»o.  782,  785. 
Hamburger,  381 . 
Hammond,  435. 
Hancoek,  21,  32,  33,  35,  47,  729. 
Harbitz,  255. 
Harley,  306. 
Harris,  370,  45.3. 
Harsha.   424. 
Hart.   227. 

Harte.  747,   7  IS,   752. 
Hartley,  249. 

Hartmann.  90,  95,  338,  311.  701,  774. 
Hartshorne,  707. 
Harvey,  47.  077. 
Hasse,  104. 

Hawkes,  508,  732.  702.  703. 
Hawkins.  52,  302.  702.799. 
Hayem,  739. 
Head,  522. 
Hearn,  447. 


sn; 


I\lil\    OF    NAM)  S. 


Heddaus,  343. 

Hektoen,  249,  272,  737. 

Helferich,  344 

Henle,   104. 

I  [< mi il in .   373,  762. 

Herlin,  191. 

Herman,  564. 

Herrgott,  731. 

Herrick,    129. 

II. mm,  372,  379. 

Hill,  359. 

Hillairet,  226. 

Hirst,  689. 

Hlawacek,  730,  731. 

Hodgkin,  14,   15. 

Hofmann,  225. 

Hofmeister,  770,  771. 

Hogarth,  472. 

Holbue,  37. 

Holmes,  B.,  204,  6S3. 

Huh,,,.,  C.  C.  372. 

Holmes,  T.  K.,  732. 

Homans,  797. 

Hopfenhauser,  346.  436,  438. 

Houston,  372,  430. 

Howard,  24,  28. 

Hunner,  791,  792. 

Huntington,  67,  78,  80,  131.  136,  153,  599. 

Husson,  10. 

Hutchinson,  377. 


Ii.iff,  450. 
Illi.li,  311,  768. 
I,  gi  .  359 
[semar,  196. 
[srael,  342,  646. 

Itir,    311. 


Jaroii.ay.  630,  632. 

Jackson,  203,  226. 

Jacobson,  504. 

Jadelot,  3.  432. 

Jaeger,  601. 

JaS6,  613,  634. 

Jalaguier,  52,  255,  382,  535,  537,  752. 

Jay,  374. 

Jeanniel,  789. 

Jervall,  320. 

Jessop,  753. 

Joffroy,  365. 

Johnson,  695. 

Jonesco,  90,  92,  93,  95,  97,  166. 

Jonnesco,  510. 

Jopson,  479,  786,  790. 


Jorand,  227. 
Jordan,   188,   193. 
Juilliard,  37,  38. 


K  \. n i  i  Km  i  .   377. 

Kader,  684. 

Kammerer,  197.  367,  535,  537, 

Karewski,    150,    156,    157.    159,  160,    163,  181, 

183,   184. 
Keen,  319,  320,  369,  103,  194,  679. 
Keirle,  796. 

Kelly,   \.  0.  J.,  316,  362,  739. 
Kelynack,  sn,  92,  94,  96,  290,  798. 
Kingdon,  204,  320,  365 
Kircher,  5S3. 
Klccki,  380. 

Klein,    261. 

Knight,  475. 

Kobler,  226. 

Kocher,  774. 

Kolaczer    7  is,  7:.:'.. 

Konig,  730,  733.  771. 

Kftrte,  244,  255.  644,  771.  778. 

Krackowitzer,  227.  320. 

Kraussold,  249,  77:;. 

Kreutzmann,  722. 

Krogius,  52.  205,  256,  260,  529. 

Krompecher,  749 

KrSnig,  732. 

Kroiilcin.  41,  42,  46,  47. 

Kruger,  700,  707,  722. 

Kucher,  583, 

Kiimmell,  686. 

Kussmaul,  645. 


Labhabdt,  735,  736. 

Lafibrgue,  93,  94,  104,  136,  138,  174,  185,  186, 

737. 
Lagoutte,  631. 
Lamers,  757. 
Lamotte,  2. 
I   in-.  21  1,  215,  222. 
Langhans,  344. 
Langheld,  227. 
Lanz,  255.  256. 
Lapeyre,  225.  466,  670,  671. 
Laplace,  396,  649,  651. 
Laroyenne,  722. 
Larret-Lamalignie,  794. 
Lartigau,  341. 
Laruelle,  254. 
Lautard,  594. 
Lee,  368. 
Lees,  476. 


INDEX    OF    NAMES. 


S17 


Le  Gendre,  730. 

Legg,  36.5,  565. 

Leichtenstem,  744. 

Lemaire,  37. 

Leman,  744. 

Lemon .  711. 

Lennander,  52,  303,  324,  359,  387,  388,  304, 

395,  499,  507,  522,  529,  535,  537,  572,  573, 

57."),   644.   64.5.  662. 
Lenzmann,  52,   136,  285,  287,  302,  306,  315, 

417,  424,  461. 
Lettau,  7S7,  789. 
Letulle,  752. 

Leudet,  24,  25,  383,  404. 
Lewis,   I).,  732. 
Lewis,  <;.,  22,  24,  25. 
Lewis,  M.  J.,  446. 
Lieberkuhn,   191. 
Lister,  36. 
Little,  92,  96. 
Lloyd,  366. 
Lockwood,  52,  SO,  92,  93,  94,  96,  9S,  145,  146. 

173,  802. 
Loison,  226.  24.3,  244. 
Longcope,  331. 
Losch,  352. 

Louyer-Villeimay,  4,  6,  10,  24. 
Lucke,  649. 
Lund,  371. 
Luschka,  91,  95,  136,  13S. 


MacMoxagle,  348,  351,  352,  413,  437.  xi>2. 
Madelung,  6S6. 
Mahomed,   42. 
Mall.   .5.5. 

Malloch,  802,  SOS,  809. 
Mallory,  226,  246,  341,  34s,  349. 
Malvoz,  255. 
Manley,  4.52,  4.53,  464. 
Mante,  733,  734. 
Manton,  358,  428. 
Marchand,  343. 
Marty,  48,  52,  798. 
Marcehal.   7.56. 
Markoe.  327.  .512. 
Marx,  735. 
Matalakowski,  77.5. 
Matterstock,  27.  227,  362.  450,  487. 
Mattheson,  391,  392,  416. 
Mauclaire,  631. 
Maurin,  249. 

Maydl.  214,  21.5,  744,  773. 
Mayo,  372,  373.  374,  377. 
McArthux,  251. 

McBurney.  13.  2d.  31.  4*.  49,  50,  51,  249,  366, 
52 


367,  529,  530,  531,  532,  533,  534,  .537,  538, 

693,  746,  747,  755. 
McCallum,  320. 
M,(  losh,  359,  450,  508,  647,  654,  732,  762,  763, 

764. 
McCoy,  208. 
Mi  I  arland,  470. 
McGill,  774. 

McGraw,  466,  47.5,  781,  785. 
McGuire,  721,  722. 
McKelway,  712. 
McKidd,  46.5.  466. 
McMurtry,  4*9,  493. 
McPhedren,  367. 
Meckel,  598. 

Melier.   1.  7.  S.  9,   10,   11,  24. 
Mendel,  363. 
Meniere,  10. 

Merling,   motto,   13,   116,  743. 
Mestivier,  2,  25,  31,  365. 
MetehnikofT,  375,  377,  379,  418,  4.54. 
Meusser,  492. 

Meyer,   667. 

McGregor,  208. 

Mikulicz,  39.  40,  41,  603,  608,  633. 

Miller.  421,  673. 

Mitchell,  364,  365.  370,  387,  657,  687. 

Mbrter,  589. 

Monk,  7.56. 

Monks,  .587,  744. 

Montgomery,  288,   147,  467. 

Montserrat,  467. 

Moore,  436. 

Morgagni,  786. 

Moriata,  367,  37S,  799. 

Morison,  7H2. 

Morn-.  277.  296.  420,  429,  529,  .537.  .538,  ,566, 

621,  649,  653,  7.52. 
Morse,   161,   462.  786.       • 
Morton.  44.  4.5,  46,  47,  529,  798. 
Moschowitz,  744. 
Mosher,  336,  762. 
Mott,   197. 
Moty.  455. 
Mudd,  372.  374. 
Muhsam,  317.  674.  677,  678,  681. 
Muller,  286. 
Mullin,  806,  808. 
Mumford,  41.5. 
Munde,  714,  733. 
Munro,  227,  243. 
Muret.  730. 
Murphy.    197,   204,   323.   321.   362.   373.    136, 

445,  489,  768. 
Musser,  196. 
Mynter.  48.  407,  479.  799. 


SIS 


IMiKX    OF    NAMES. 


N  \\.   REDE,    587. 

Nanninga,   1  16 
Nassau,   139. 

Vital.  .  376 

Nruiiianii,  hi:;.  Slid. 

Nicolayson,  380. 

Nietert,   108. 

Nint,  715. 

Noble,  ('.  P.,  358,  123,  538,  539. 

Noble,  G.   B.,  359. 

Norris,  744,  749,  753. 

Nothnagel,  154,  211,  214,  486,750. 

NToyes,  37,  38. 

Nut  tall,   261. 


Ochsner,  211,  368,  3S6,  423.  446,  510,  802. 

Officer,  368. 

Olmstead,  808 

i  Ippenheim,  H72. 

i  Ippenheimer,  732. 

i  Ippolzer,  25. 

(H-ili,  597,  .Vis,  599,  787. 

Osier,  303,  352,  382,  404,  419,  422,  4117,  518, 

599,  601. 
Oviatt,  602,  738,  739. 


Paak,  261. 

Park,  366,  686. 

Parker,   R.    II.,  797. 

Parker,   W  ,  26,  34,  37,  43,  47. 

Parkinson,  34,   150. 

Parrot,  365. 

Partsch,  342,  343. 

Pat. 4.  r.27.  630,  631. 

Paviot,  381. 

Pawlowsky,  254, 

Payne,  202,  213,  365,  662. 

Pearce,   18,  246. 

Penrose,  732. 

Pepper,  is. 

Perignon,  91,  95. 

Perkins,  677,  678,  079. 

Perret,  798 

Petel,  332,  333. 

Peterson,   P.,  758,  759,  77:; 

Peterson,  R.,  632. 

Petrequin,  51 1,  794 

Petrevsky,  260. 

I'iar.l,  244,  671. 

Piersol,    180. 

Pilliet,  244,  338,  341,  761,  775. 

Pitts,   171 

Poirier,   104,   Is.",. 

Poljakow,  383 


P :et,  386,  636. 

Pond,  388,   12:,.  506,  800. 

Pooley,  202. 

Porter,  C.   B.,  52,   181. 

Porter,  M.   1  •'.,  489,  674,  676. 

Powell,  .1     li  ,  206. 

Powell,  N.  C,   110. 

Powers,  681. 

I'.izzi,  321,  698. 

Predohl,  254. 

Price,  721. 

Pruss,  743,  786,  7s7.  789. 

Puchelt,  12.  1  I.  17. 

Pulsford,  439. 


iii  i.m  .  415,  029. 
Quinard,  410. 


Rabe,  227. 

Ramond,  341. 

Ransohoff,  249,  372. 

Ravaut,  341. 

Reamy,  18. 

Reclus,  380,  381. 

Reichel,  652. 

Reisinger,  302. 

Rendu,  334. 

Renshaw,  473. 

Renvers,  303,  323.  487. 

Retzius,  His,  169. 

Reyling,  717. 

Reynes,  403. 

Ribbert,  135,  130,  137,  149,  150,  152,  250,  290, 

292,   357,  480. 
Ricard,  333. 
Richard,  322. 
Richards,  17,  is. 
Richardson,  motto,  is.  52,  388,  390,  391,  397, 

421.  129.  130,  132.  iin.  157,  163,  mi,  197, 

498,  "hi:,,  .v.iii,  c,ii7. 
Richelot,  330. 
Riedel,  52,  284,  357,501. 
Riefkohl,  601. 
Ritzel,  419. 
Rivet,    179,  786. 

II. .aril.     182. 

Robb,  377.  705.  719. 

Roberts,  367, 

Robinson,  121.  130,  134,  130,  137,215,249,250, 

358,  587. 
Robsoh,  721,  731,  739. 
Roger,  2.79.  380 
U.iL'.r-.    303. 
Rog<  rs,    !...   353.    351.   7711 


INDEX   OF   NAMES. 


819 


Rokitansky,  21,  743,  751,  752,  7S7. 

Rolleston,  89,  92,  93,  369,  433,  746,  748,  755. 

Rotter,  627,  031. 

Rouget,  104. 

Rousseau,  420. 

Routier,   340. 

Roux,  52,  321,  357,  399,  582. 

Runyon,  2S7,  709. 

Rushmore,  489. 

Russell,  421,  607. 

Rydygier,  565. 


Sachs,  215,  774. 

Sahli,  302,  316,  357. 

Sallet,  636. 

Salmon,  260. 

Salzer,  775. 

Sambl,  353. 

Sandefort,  787. 

Sands,  46,  47,  433,  435,  529. 

Sanger,  610. 

Sappey,   168,  169. 

Schede,  322,  686. 

Scheibenzuber,  209,  333. 

Schlafke,  492. 

Schleich,  250. 

Schmidt,  A.,  37. 

Schmidt,  J.  C,   13,   14,  225. 

Schooler,  369. 

Schuller,   529. 

Schultze,   104. 

Sears,  360,  372. 

Sedillot,  3 IS. 

Selmer,  37. 

Seller,  450,  452,  456,  457,  482,  483. 

Senn,  48,  49,  292. 

Sharp,   802. 

Sheen,  227. 

Shober,  701. 

Shoemaker,  196,  243,  244,  366,  701. 

Sholler,  377. 

Siegel,  714. 

Simon,    lis. 

Skene,  52,  567. 

Small,  796,  800. 

Smith,  192,  260. 

Sonnenburg,  52,  215,  227,  291,  303,  313,  316, 
317,  322,  323,  336,  382,  488,  400,  101,  529, 
672,  073,  675.  670,  6S0,  740,  755,  757,  762, 
763. 

Soranus,  31. 

Southam,   t\   A.,  490. 

Southam,  <'...  7!v0. 

Southerland,  357. 

Spickenbaum,  196. 


Spfflissy,  414,  418,  420,  421,  424. 

Starling,  193. 

Steensland,  285. 

Steiner,  250. 

Steinhal,  649. 

Still,  455. 

Stimson,  35,  755. 

Stohr,  357. 

Stokes,  J.  E.,  404. 

Stokes,   R.  J.,  357,  511. 

Stone,  372. 

Stooke,  227. 

Strickler,  C,  732. 

Strumpcll,  486. 

Stumpf,  729. 

Suchier,  773. 

Summa,   700,  710. 

Sutherland,  455. 

Sutton,  B.,  449,  455. 

Sutton,  E.  M.,  631. 

Symonds,  42. 

Syms,  367. 


Tait,  38,  716. 
Talamon,  52. 
Tavel,  255,  256. 
Tchacaloff,  292. 
Terillon,  69S. 
Terrier,  603,  622,  623. 
Thfidenot,  769. 
Thomason,  733. 
Thorndike,  744,  755. 
Thurnam,  373. 
Tietze,  652. 
Tirifahy,  375. 
Tixier,   184,   185,  186. 
Toft,  249. 
1  Toldt,  91,  95. 
Treves,  45,  46.  47,  48,  40,  52,  so.  oo,  91,  92, 
93,90.  105,  106,  119,  128,  137,  138,  391,  loo. 
402,  410,  414.416,420,424. 
Trimble,  280,  739 
Tripier,  381. 
Trowbridge,  227. 
Turner,  52,  90,  92,  95,  500,  730. 
Turk,  3S3. 


Umber,  214,  222. 


Vm.i.ki:.    13S.    1  IS. 
Vallin,  104. 
Van   Arsdale,  054. 
Van  Cott,  592. 


820 


INDEX    OF    NAMES, 


Van   Honk,  622    790 
Van  Lennep,  193,  498,  508,  651,  674. 
Will,,,,.  256,  261. 
Veron,  :;7^ 

Vianney,  184,  1^5.  186. 
Vigniard,  507. 
Virchow,  291,  f.72.  787. 
Volz,  motto,   L9,  21,  511. 
\',,u   Baracz,  080. 
Von   Bergman,  502. 
Vm,  dem  Busch,   192. 
Voi,   Eiselsberg,   I'M.  680,  780. 
Von   Faber,  481. 
\  on  Ley  den,  21  I. 
Von   Mot  v.  375,  455. 
Von  Wahl,  684 
Voron,  428. 
191. 


Walch,  663. 

Waldeyer,  90,  02.  94    96 

Wallace,  ('.  S.,    HI, 

Wallace,  W.   I...  203. 

Waller,  226. 

Wallis,  249. 

Walsham,  371.  578,  619. 

Ward,  -V.  373 

Ward,  O.,  797. 

Warren,  373.  621,  653,  75S,  773. 

Warrinpton.   18. 

Wassalief,  774. 

Waterhouse,   165 

Watkins,  723. 

Watney,  357. 

Weaver,  90,  98,  120,  137. 


Weber,  36,  215.  222. 

w  i  gi  ler,  4. 

\\  ciclisclhaum,   251.   7  1 1. 

Weigert,  342 

Weinburg,  752. 

Weir,  48,  49,  278,  61  I.  615,  711.  755. 

Welch,  255,  260.  261.  328,  332,  672. 

Werder,  706,  716. 

Westermann,   176. 

Wetherill,  371. 

Whipham,  366,  756. 

Wickershauer,  706. 

U  igan,  710. 

\\  il'j:h,~,  7  Hi. 

Willard,  366. 

Williams    I),   511. 
William-.    V.    II  .   643, 
Wilson,  717.  752,  748. 
Winge,  37. 
With.  27. 
Witzel,  642. 
Wolbrecbt,  387 

Wolfler,  251,  292,  780,  783,  790. 
251  I 

\\ Ibury,  41.   15. 

Worcester,  31,  is.  51,  202.  45S,  539,  667. 
Wright.  G.  A..    173,  7.",:; 
Wright,  "I     l:..  371. 

Yates,  261. 

Zeller,  567. 
Zuber,  256,  261. 
Zuckerkandl,  136,  152,  250,  292. 
Zweifel,  701. 


INDEX. 


Abdominal  cavity :  irrigation  of,  in  general 
purulent  peritonitis,  647-652;  power  of  ab- 
sorption in,  304-306;  sensibility  of,  305,  321, 
322. 

Abdominal  fossa-,  611,  612. 

Abnormal  positions  of  the  appendix;  due  to 
arrested  development,  133-135;  due  to  dis- 
placement. 1 31 1-132;  due  to  length  of  mes- 
entery, 132,  133. 

Abortion,  criminal,  mistaken  for  appendicitis, 
S09,  810. 

Abscess  of  kidney  in  appendicitis;  natural  his- 
tory of,  208;   post-operative  sequela,  667. 

Abscess  of  liver  in  appendicitis;  at  autopsy, 
226-246;  complication,  402;  natural  history 
of,  209. 

Abscess,  peri-appendical;  at  autopsy,  213;  be- 
tween layers  of  mesentery,  313,  624-627; 
encapsulated  in  omentum,  622;  gangrenous, 
622-624;  pathology  of,  312-314;  resolution 
of,  316;  results  of,  316-322;  treatment  of, 
313,  614-622;  treatment  of,  in  special  cases, 
622-627, 

Abscess,  peri-appendical,  rupture  of;  into  ab- 
dominal wall,  316,  317;  into  bladder,  204, 
318-320;  into  cecum,  204;  into  gall-bladder, 
317;  into  gluteal  region,  205;  into  intestinal 
tract,  317;  into  popliteal  space,  205;  into 
rectum,  204;  at  umbilicus,  204  ;  into  vagina, 
204,  317;    under  crural  arch,  205. 

Abscess,  pelvic  peri-appendical:  at  autopsy, 
213,  214;  frequency  of,  627;  para-sacral 
method  of  opening,  630;  perineal  method 
of  opening,  631;  symptoms  of,  628;  treat- 
ment of,  628-632;    varieties  of,  027. 

Abscess,  perinephritic,  424. 

Abscess,  retro-peritoneal,  314-316. 

Abscess,  subphrenic,  in  appendicitis;  at  au- 
topsy, 214-225;  complication.  402:  etiology 
of,  636,  637;  symptoms  of,  637,  638;  treat- 
ment of,  638-641. 

Acetonemia  as  a  post-operative  sequela,  668, 
669. 

Actinomycosis,  appearance  of  at  operation, 
776;    clinical  history  of,  768,  769;    in  child, 


481,  482;  etiology  of,  669,  670;  frequency 
of,  196;    pathology  of,  342-347. 

Adhesions:  between  appendix  and  site  of  previ- 
ous operation,  719-723;  delicacy  of,  in  child, 
45S;  treatment  of,  in  removal  of  appendix, 
575-587. 

Amoebic  dysentery,  clinical  history  of,  770, 
771;    pathology  of,  352-354. 

Anastomosis  of  intestines,  777-7S5. 

Anatomical  bibliography,  18,8,  189. 

Anatomy  of  appendix  in  child,  451,  452. 

Anesthesia,  516-522. 

Anus  pretermit uralis,  680. 

Appendices;  abnormally  long,  136;  misplaced, 
135;    supernumerary,  135. 

Appendicitis,  acute  catarrhal:  natural  history 
of,  199;    pathology  of,  264-266. 

Appendicitis,  acute;  complications  of.  398-404  ; 
diagnosis  of ,  407— 414 ;  differential  diagnosis 
of,  414-430;  exciting  causes  of,  360-380; 
final  causes  of,  380-384;  first  recorded  case 
of,  2;  frequency  of,  210,  211 ;  medical  treat- 
ment of,  510-513;  natural  history  of  acute 
and  chronic,  19S,  199;  origin  of  name,  29; 
pathological  classification,  26.3.  264;  predis- 
posing causes  of,  357-360;  symptoms  of, 
386-398. 

Appendicitis,  acute  diffuse;  histology  of,  266; 
pathology  of,  268. 

Appendicitis,  chronic  adhesive,  249,  250. 

Appendicitis,  chronic  diffuse;  complications  of, 
405,  406;  histology  of,  284,  285;  forms  of, 
4ii5;  pathology  of,  278-285;  rigidity  of  ap- 
pendix in,  279;    symptoms  of,  405.  406. 

Appendicitis,  chronic  obliterative,  250. 

Appendicitis,  gangrenous,  269-271. 

Appendicitis  larvata,  405,  458,   159. 

Appendicitis,  perforative.  276-278. 

Appendicitis,  purulent,  268,  269. 

Appendicitis,  residual.  278,  287,  288 

Appendicitis,  traumatic,  795  S03. 

Appendicitis,  ulcerative,  285-287. 

Appendico-cecal  junction.  lymphatics  of,  174. 

Appendiculo-ovarian  ligament,  102-104. 

Appendix;  arteries  in,  155-106;    coats  of,  139- 


S21 


822 


INDEX. 


146;  contents  of,  148,  149;  dimensions  of 
135  L39:  distortions  of,  121.  125.  126,  199; 
embryology  of,  55-71 :  exposure  of,  in  opera- 
tion on,  540  546;  function  of,  190  193; 
glands  of,  144-1  16,  184  186;  lymphatics  of, 
169  17:;.  333,  334;  lymph  nodes  in,  146- 
lls:  movements  of,  193,  194;  nerves  of, 
186-lss:  position  of,  118-135;  retrogression 
of,  152-154;  structure  of,  139  148;  tran- 
sient, 56—58;    veins  of,  166—169. 

Arteries,  appendical;  arrangement  of,  164  166; 
embolism  of,  208,  209;  method  of  injecting, 
161;    origin  and  number  of,  156-161. 

Arteries  of  mesappendix,  161. 

Arterio-sclerosis,  248. 

Aiitn  infection  as  a  post-operative  sequela, 
668,  669. 

Autopsy  records,  bibliography  of,  252,  253. 


Bacteria  in  appendix;  conditions  favorable 
for  development  of,  256,  257;  species  of, 
present,  257  260. 

Bacteriological  bibliography,  261,  262. 

Bibliography,  anatomical,  188,  189;  autopsy, 
252,  253;  bacteriological.  261,  262;  histori- 
cal, 52,  53;   pathological,  354  356. 

Bladder;  adhesion  of,  to  appendix,  107,  204, 
205,  318-320;  symptoms  in  appendicitis, 
387. 

Blood-vascular  infection,  328-333. 

Bone,  pieces  of,  in  appendix,  373.  37 1. 

Bowels;    care    of,    after    operation,    058,    659; 

treatment    of,   in   acute   appendicitis,    511- 

513. 
Bradford    frame,    use    of,    in    appendicitis    in 

child,  184. 
l?ri~tle.  piece  of,  in  appendix,  373. 


CARCINOMA    of   the   appendix:   clinical   history 

of,  743-757;   operation  for,  772,  773. 
Carcinoma,  differential  diagnosis  between,  and 

appendicitis,  417,  409.  470. 
Causes     of     appendicitis;     exciting,    360-3S0; 

final,   380  384;   predisposing,  357-360. 
Cecal  apparatus,  function  of,  7s   so. 
Cecal  glands,  isolated,  1S3,  184. 
Cecum;   appendical   abscess  discharging   into, 

204;   resection  of ,  475-177 ;  types  of.  so  s5. 
Cecum,  primary  ulceration  of,  302,303;  eases 

of,  188    192;  diagnosisof,  192,  193;  operation 

for.   193. 
Cecum,  varieties  of  ulceration  in.  480,  487. 
Child,  appendicitis  in;  age  for,  451 ;   delicacy 

of  adhesions  in,  458;   diagnosis  of,  459   182; 


examination  by  rectum  in,  456;  examination 
of  thoracic  viscera  in,  157;  gastro-intestinal 

disturbance    in,    157.     158;     history    of,    150, 

151;   sympt s  of,  155   159;   treatment  of, 

ts_'   iM;  vomiting  as  sole  symptom  of ,  156, 

157 

t  'lull-,  symptom  of  appendicitis,  394 

Cigarette  drains,  621,  653 

Clado's  gland,  184. 

Coats  of  the  appendix,  139  1  Is. 

Colic  glands,  isolated,  183,  184. 

Complications  of  acute  appendicitis,  general 
peritonitis,  3! Ml- 101  ;  hemorrhage,  104;  ileus, 
401  :  liver  abscess,  102;  lung  affections, 
402,  Hi3;  pleural  affections,  102,  103;  pye- 
mia, 402;  pylephlebitis,  102;  septicemia, 
401;  subphrenic  abscess,  102;  suppurative 
peri-appendicitis,  398,  399;  vesical  and  renal 
affections,    103,   104. 

Complications  of  chronic  appendicitis,  405, 
400. 

Concretions,  fecal:  appearance  of,  lis,  149; 
cause  of  appendicitis,  302-305;  cause  of 
appendicitis  in  child,  104;  method  of  develop- 
ment of,  199,  300,  301;  pathology  of,  298- 
301. 

Connell's  method  of  intestinal  anastomosis,  785. 

Constipation  ;  symptom  of,  acute  appendicitis, 

391;    of  chronic  appendicitis,  405. 
Contents  of  appendix,    I  IS. 
Cutaneous  hyperesthesia  in  appendicitis,  389. 

Cystitis  in  appendicitis;  post-operative  sequela, 

007,  668;    symptom,  403,     101 
Cysts,  appendical,  250-251,  288-292. 


DIAGNOSIS  of  appendicitis,  407-414;  in  child, 
459-482. 

Iiiet  after  operation,  657. 

Differential  diagnosis  between  appendicitis 
and;  actinomycosis,  481,  482;  carcinoma, 
417;  coxitis,  427,  128,  178,  170;  foreign 
bodies  in  intestine,  415;  gall-bladder  affec- 
tions, 414,  415;  gastro-intestinal  affections, 
414-41S;  gynecological  affections,  427;  hy- 
pochondriasis and  hysteria.  428;  hernia, 
418,  180,  481 ;  ileocecal  tumor,  416,  117;  in- 
testinal obstruction,  417,  41S;  intestinal 
parasites,  418;  intramuscular  abdominal 
abscess,  127;  intussusception,  lis.  101-478; 
kidney  affections.  421-421;  mesentery,  af- 
fections of,  410,  420;  ovarian  disease,  181, 
715,  716;  pancreatic  disease,  426,  427;  pel- 
vie  inflammation,  711-717;  perinephritic 
abscess,  424;  peritoneal  affections,  419- 
421;  pneumonia  and  pleurisy  in  child,  400- 


INDEX. 


823 


463;  psoitis,  acute,  427;  pyonephrosis,  423, 
424;  renal  tumor,  424;  tubercular  peritoni- 
tis, 463-481;  typhoid  fever,  459;  vertebral 
disease,  427. 

Differentiation  between  appendix  and  cecum 
in  embryonic  life,  72-77. 

Digestive  disorders  as  a  cause  of  appendicitis, 
360,  361. 

Dimensions  of  appendix,  135-139. 

Diseases  to  which  appendix  is  liable,  natural 
history  of,  195-198. 

Displacements  of  appendix,  131-133. 

Distention  of  abdomen,  as  symptom  of  appen- 
dicitis, 397. 

Distortions  of  appendix,  124,  125,  126,  199. 

Diverticula,  false,  594. 

Diverticulitis,  602. 

Diverticulum,  Meckel's :  arteries  of,  599 ;  attach- 
ment of,  597,  598 ;  embryology  of,  595,  596 ; 
mesenteriolum  of,  600,  601 ;  size  of,  596, 
597;   types  of,  596. 

Drainage ;  in  appendical  abscess,  620-622 ;  in 
diffuse  purulent  peritonitis,  652-654;  in 
pelvic  abscess,  632. 

Drainage,  best   material  for,  621. 

Drains,  cigarette,  621,  653. 

Dysmenorrhea  in  chronic  appendicitis,  406, 
698. 


Ectopic  gestation.  See  Extra-uterine  preg- 
nancy. 

Effects  of  an  appendicitis  upon  the  appendix 
itself,  natural  history  of,  199,  200. 

Effects  of  an  appendicitis  upon  neighboring 
structures,  natural  history  of,  201-204. 

Embolism;  of  appendical  arteries,  208,  209; 
of  coronary  arteries,  248,  249;  of  pulmonary 
artery,  208,  248;  of  tibial  artery,  208,  333. 

Embryology  of  the  appendix,  55-71. 

Empyema;  of  the  gall-bladder,  425;  of  the 
pleura,  459. 

Endocarditis,  248. 

Entero-enterostomy,  778-780. 

Enteroliths.     See  Concretions. 

Enterostomy,  654. 

Epididymitis  as  a  post-operative  sequela,  667. 

Etiology  of  appendicitis;  age  in,  35S,  452,  453; 
digestive  disorders  in,  360,  361,  151;  foreign 
bodies  ami  concretions  in,  362-374,  379,  380, 
451;  floating  kidney  in,  358;  heredity  in, 
359.361);  infectious  diseases  in,  381-383;  in- 
testinal parasites  in,  374-377;  menstruation 
in,  361;  microbic  infection  in,  380;  nation- 
ality in.  359;  sex  in,  358,  359;  trauma  in. 
See  Traumatic  appendicitis. 


Examination  of  appendix  whenever  the  abdo- 
men is  opened,  717. 

Examination  of  patient  in  appendicitis,  410- 
414,  455-459. 

Exposure  of  appendix,  method  of,  540-546. 

Extra-uterine  pregnancy;  diagnosis  between, 
and  appendicitis,  734,  operation  for  appen- 
dicitis in,  72S. 


Fibroma  of  appendix,  740-743. 

Fibro-myomata  of  appendix,  196,  739. 

First  recorded  ease  of  appendicitis,  2. 

Fish-fin  in  appendix,  374. 

Fistula,  intestinal,  317,  318,  674-681;  urinary, 
318-320,  681,  682. 

Floating  kidney  a  cause  of  appendicitis,  358. 

Folds;  ileocecal,  90-92;  ileocolic,  89,  90;  peri- 
cecal, 86-88;   retrocecal,  99-102. 

Forceps,  Eastman's  572,  575;    mosquito,  515. 

Foreign  bodies  in  appendix ;  cases  of,  365-374 ; 
etiologic  relation  of,  to  appendicitis,  362- 
365;  pathogenesis  of,  in  appendicitis,  377- 
380. 

France;  early  history  of  appendicitis  in,  2-11; 
first  reported  ease  of  appendicitis  in,  2. 


GALL-ni.ADDKn,  disease  of,  mistaken  for  ap- 
pendicitis, 124-426. 

Gall-stones  (supposed)  in  the  appendix,  363, 
364. 

Gangrenous  appendicitis,  269-271. 

( las-formation  as  a  post-operative  sequela,  664. 

Gastric  lavage  in  treatment  of  appendicitis, 
510. 

Gastro-intestinal  disease  mistaken  for  appen- 
dicitis, 414-41S. 

Gastro-intestinal  symptoms  in  appendicitis, 
457. 

General  appearance  in  appendicitis,  398. 

Germany,  early  history  of  appendicitis  in, 
12-14. 


Heart,  condition  of,  in  appendicitis  at  au- 
topsy, 24S. 

Hemorrhage  in  appendicitis;  complication, 
4it4;  post-operative  sequela,  662, 663;  symp- 
tom, 391.  392. 

Heredity  in  the  etiology  of  appendicitis,  359, 
360. 

Hernia  of  appendix;  acquired,  787-789;  con- 
genital, 7x7  ;  diagnosis  of,  791  :  frequency  of, 
27.2,   7S6.   7X7:    treatment    of.   791-793. 

Hernia  of  appendix,  in  child,  I7!i  481, 


824 


INDEX. 


Hernia,  intestinal;  mistaken  fur  appendicitis, 

tls;    post-operative  sequela,  692  697. 
History  of    appendicitis  in;    England,   14-17; 

France,    2-11;     Germany,     12-14,     19-21; 

United  States,  17-18,  22  24,  28  30. 
History  of  appendicitis,  surgical,  31-52. 
Hypochondriasis    mistaken    for    appendicitis, 

128 
Hysteria  mistaken  for  appendicitis,  l_'s. 


Ice  in   treatment    of  appendicitis,  511. 
II lecal  artery,   155,    150. 

Ileocecal  fold,  90  92. 

Ileocecal  region :  lymphatics  of,  173,  171;  inner 

surface  of,    1  10-117. 

Ileocecal    tu r;    mistaken    for    appendicitis, 

llli,    117;    operation   for,   770-785. 

Ileocolic  artery,  155. 

Deocolic  fold,  89,  90. 

Hens,  in  appendicitis;  complication,  401;  in- 
dication for  operation,  499,  500;  post-oper- 
ative sequela,  683-692. 

Ileus  mistaken  for  appendicitis,  499,  500. 

Iliac  artery,  hemorrhage  from  adhesion  of,  to 
appendix,  206,  207. 

Incision  in  appendicitis:  closure  of,  538,  539; 
double,  483,  538;  general  rules  for,  523; 
lateral,  723-725;  median,  524,  531,  723; 
Oblique,  531.  532;  semilunar,  531-537.  723; 
vertical,  521,  527. 

Incision  in  appendicitis;  methods  for,  Battle's, 
534-537;  Edebohls's,  538;  Finney's  modi- 
fication of  McBurney's,  531;  fowler's,  531, 
532;  McBurney's,  533,  534,  735;  Morris's, 
:.;:s;  Roux's,  532:  Sonnenburg's,  529,  531. 

Incision  for  ileocecal  tumor,  774. 

Incision  in  diffuse  purulent  peritonitis,  C46, 
(117 

Indican,  presence  of,  in  urine,  401,  411,  442. 
Indications  for  operation  in  appendicitis,  496- 

500. 
Indigestion,  acute,  mistaken  for  appendicitis, 

459. 
Infarction,  intestinal,  in  appendicitis,  331,  332. 
Infection,  peritoneal,  varieties  of,  306. 
Inferior  pelvic  abscess,  1127,  628. 
Intermediate  operation   for  appendicitis,  503- 

506. 
Interval  operation  for  appendicitis;  definition 

of.  506;  first  performed,   42,  43;    safety  of, 

507;    time  for,  507,  508. 
Intestinal  anastomosis,  methods  of,  778-785. 
Intestinal  fistula;  pathology  of,  317-318;    as  a 

post-operative  sequela,  074-681. 
Intestinal  parasites,  374-377,  454,  455. 


Intestines,    condition    of,   at    autopsy    in    acute 

appendicitis,  217;    lifting  out  of  abdominal 
cavity,  017;    irrigation  of,  017   019;    wiping 
off,  052. 
Intramuscular    abdominal    abscess,    mistaken 
for  appendicitis,  427. 

Intra-tlioracie  affections,  mistaken  for  appen- 
dicitis,  129,    130.  400    103. 

Intussusception,  101  175;  mistaken  for  appen- 
dicitis, lis. 

Intussusception  of  appendix,  mistaken  for  car- 
cinoma,  109,    170. 

Inversion  of  appendix,  164,  168,  474,  475. 

Irrigation  of  peritoneum,  017   052. 


Jaundice,  symptom  of  appendicitis,  379,  398. 


KlDNEY,  aliseess  of,  in  appendicitis;  history  of, 

208;    post -operative-  sequela,  007. 
Kidney,  condition  of,  in  acute  appendicitis  at 

autopsy,  210,  247. 
Kidney,  disease  of:  complication  of  appendi- 
citis,   103,   lot;    mistaken  for  appendicitis, 

121     121. 

Kidney,   Boating,   mi-taken    for  appendicitis, 
421-424. 


I.wn  \iss  as  a  symptom  of  appendicitis  in 
child,   458,    159.  ' 

Larvate  form  of  appendicitis,  458. 

Late  operation   for  appendicitis,  500. 

Lateral  incision.  524.  531. 

Lead  colic,  mistaken  for  appendicitis,  419. 

Length  of  appendix.   135    138 

Leucocyte  count;  in  diagnosis  of  appendicitis, 
430;  in  diagnosis  between  appendicitis  and 
typhoid  fever,  111;  as  indication  for  opera- 
tion, 499. 

Lipoma  of  mesentery,    120. 

Liver  aliseess  in  appendicitis;  at  autopsy,  220, 
227;    as  complication,    102. 

Liver,  acute  yellow  atrophy  of,  628,  683. 

I.oe.,1   anesthesia,   519-522. 

Lungs,  condition  of,  in  appendicitis  at  autopsy, 
217. 

Lungs,  disease  of,  in  appendicitis;  complica- 
tion, 402,  403;  post-operative  sequela,  072- 
074. 

Lymph  nodes  in  appendix,   110    lis. 

Lymphatic  infection  of  appendix,  3.33  334. 

Lymphatics  of  appendico-cccal   junction,  174. 

Lymphatics  of  appendix,  109-173. 

Lymphatics  of  ileocecal  region,  173,  174. 


INDEX. 


Nltf 


McGraw's  method  of  intestinal  anastomosis, 

781-785. 
Meckel's   diverticulum;    attachment    of,    597; 

blood-supply  of,  599-601 ;    embryology  of, 

595,  596;    pathology  of,  601,  602;   size  of, 

596,  597;    structure  of,  599. 
Median  incision,  524,  531,  723. 

Medical  treatment  of  appendicitis,  510-513. 

Medico-legal  complications  in  appendicitis,  l!i7, 
704-706,  806-811. 

Menstruation,  disturbance  of,  a  symptom  of 
appendicitis,  361. 

Mesappendix;  arteries  of,  161;  glands  in, 
186;  length  of,  affecting  position  of  appen- 
dix, 125,  126,  132;  ligation  of,  552-555; 
lymphatics  of,  183;    veins  of,  167. 

Mikulicz's  natural  harriers  of  infection.  603. 

Misplaced  appendices,  135. 

Movements  of  appendix,  193,  194. 

Muscle  spasm  in  appendicitis:  indication  for 
operation,  497;    symptom,  390. 

Myoma  of  appendix,  707,  739,  74o,  772. 

Myxoma  of  appendix,  739. 


Nail  in  appendix,  374. 

Nationality  in  etiology  of  appendicitis,  359. 

Natural  history  of;  acute  and  chronic  affections 
of  the  appendix,  diseases  to  which  appendix 
is  liable,  195-19S;  effect  of  an  appendicitis 
on  the  appendix  itself,  199,  200;  effect  of  an 
appendicitis  on  neighboring  structures,  201- 
205;  more  remote  effects  of  an  appendicitis, 
205-209. 

Needle-holders,  515. 

Neoplasms  of  appendix;  at  autopsy,  252;  be- 
nign, 737-743;    malignant,  743-7.51. 

Nerves  of  appendix,  186-188. 

Nervous  mauifi  stations  as  post-operative  se- 
quela-, 669,  670. 

Nitrous-oxid  anesthesia,  516-517. 


Obliteration  of  appendix,  149-152,  199,  292- 
29S,  594. 

Obscure  and  masked  forms  of  appendicitis,  410. 

Omentum,  adhesion  of;  to  appendix,  583-584; 
gangrene  in,  mistaken  for  appendicitis,  4211; 
protection  of  appendix   by,  30S. 

Operation  in  appendicitis;  care  of  patient 
after,  655-660;  cleansing  the  field  of.  514; 
early,  501  503;  foreign  views  on.. 502;  ideal 
time  for,  .502;  in  desperate  cases,  184,  508, 
509;  indications  for,  496-500;  instru- 
ments for,  515,  516;  intermediate,  .503- 
506;  interval,  506-508;    late,  506;   prompti- 


tude in,  500.  501;  severe  symptoms  follow- 
ing, 659,  660. 

i  Operation  for  ileocecal  tumor,  772-785. 

(  ipiuni  in  the  treatment  of  appendicitis,  19- 
21,  511-513. 

< >rigin  of  name  appendicitis,  29. 

Ovarian  cyst,  tor-ion  of,  mistaken  for  appen- 
dicitis, 481,  71.5,  710. 

Ovarian  tumors  complicating  appendicitis, 
705-707. 


Pain  in  appendicitis;  indication  for  operation, 
407;    in  scar,  061;   symptom,  386-388,  405. 

Pancreatic  disease,  mistaken  for  appendicitis, 
426,  427. 

Patient,  care  of;  after  operation.  0.5.5  000; 
preparation  of,  for  operation,  .514. 

Pathological  bibliography,  3.54-3.50. 

Pelvic  appendieal  abscess.  See  Abscess,  ap- 
pendical. 

Pelvic  disease;  as  cause  of  appendicitis,  703- 
709;  coincident  independently  with  appen- 
dicitis, 709,710;  secondary  to  appendicitis, 
700-703;  treatment  of,  when  associated 
with  appendicitis,  717-72X. 

Pelvic  disease;  diagnosis  between,  and  appen- 
dicitis, 711-715;  in  appendicitis  at  autopsy, 
252. 

Pelvic  position  of  appendix,  130. 

Peri-appendical  abscess,  213,  027. 

Peri-appendicitis;  mistaken  for  appendicitis, 
409;  suppurative,  complication  of  appendi- 
citis, 398,300.     See  Abscess,  peri-appendical. 

Pericecal  fold-.  86  88 

Perinephritic  abscess  mistaken  for  appendicit  is, 
424. 

Peritoneum,  affections  of,  as  complications  of 
appendicitis,  419-421. 

Peritoneum;  condition  of,  at  autopsy  in  acute 
appendicitis,  212;  irrigation  of,  647-652; 
reflection  of,  104-110;  structure  and  func- 
tion of,  303-306. 

Peritonitis,  diffuse  purulent;  definition  of,  041, 
042;  diagnosis  of,  042,  043;  prognosis  of, 
013.   011  ;    treatment    of,   644-654. 

Peritonitis,  disseminated  focal,  206,  033-636. 

Peritonitis,  dry,  324. 

Peritonitis,  general;  complication  of  appendi- 
citis, 399-401;   pathology  of,  322-327. 

Peritonitis   in   general,   302-306. 

Peritonitis,  localized.  306  312. 

Peritonitis,  progressive,  fibrino-purulent,  206, 
633-030 

Peritonitis  scptica,  324. 

Perityphlitis  typhosa,  442,  443,  444. 


826 


INDEX. 


Phlebitis  in  appendicitis,  at  autopsy,  226; 
pathology  of,  328  333. 

Piez iter,   112.  413. 

Pins  in  appendix.  365  372. 

Pin-worms  in  appendix,  375  377. 

Pleura,  condition  of,  in  acute  appendicitis  at 
autopsy,  -17. 

Pleuritis;  complication  of  acute  appendicitis, 
402,  103,  160-463;  post-operative  sequela, 
670  672 

Point  uf  origin  df  appendix,  118  124. 

Polypi  of  appendix,  280,  737  739,  772. 

Po  n  ion  of  appendix,  1 18-  I  35. 

Post-operative  sequelae;  abscess,  667;  acetone- 
mia, 668,  669;  acute  yellow  atrophy  of 
liver,  682,  683;  bronchial  catarrh,  670;  can- 
cer of  wound,  667;  cystitis,  667, 668;  epididy- 
mitis, 667;  gangrene  of  wound.  664;  gas 
formation,  664;  hemorrhage,  662,  603: 
hernia,  692-697;  ileus,  683-692;  intestinal 
fistula,  674-681;  nervous  manifestations, 
669,  670;  lung  complications,  672  764; 
pain  in  scar,  661,  662;  pleurisy,  670  i '■  7 _' : 
pulmonary  embolism,  672-674;  pyelitis, 
667;  skin  affections,  682;  suppuration  of 
abdominal  wound,  663,  664  ;  urinary  fistula, 
681,  682. 

Post-typhoid  appendicitis,  38,   139 

Posture  of  patient  after  operation,  514. 

Prececal  position  of  appendix,  123 

Pregnancy,  appendicitis  during;  diagnosis  of, 
7:;:;.  734;  effect  of,  731-733;  treatment  of, 
734   736 

Pregnancy,  diagnosis  between,  and  appen- 
dicitis, 733,  734. 

Preparations  for  operation,  513-516. 

Psoitis,  acute,  as  complication  of  appendicitis, 

427. 

Pulse,  symptom  of  appendicitis,  394,  395,  499; 

indication  fur  operation,   199 
Pyelitis   in    appendicitis;    complication,"  402; 

post-operative  sequela,  067. 
Pyemia,  402. 
Pylephlebitis  in  appendicitis;  at  autopsy,  226, 

227;    complication,    102. 
Pyonephrosis  mistaken  for  appendicitis,  423,424. 


Rectal  symptoms  in  appendicitis,  387,  628. 
Rectum;   discharge   of   appendix    from,  203; 

drainage  by,  628;  examination  by,  113,  156, 

628. 
Relations  between  physician  and  surgeon,  494. 

49.5. 
Remote    effects    of    an    appendicitis,    natural 

history  of,  205-209. 


Removal  of  appendix  ;  in  absence  of  mesentery, 
583;  in  extra  uterine  pregnancy,  72s ;  in  pel 
vie  disease,  725—728;    by  stripping  out,  576; 
in  suppurative  cases,  612-617. 

Removal  of  appendix;  evolution  of  technic  in, 
is  52;  first,  11,  12;  firsl  successful,  H. 
45;    incidental,  495;    prophylactic,  717  719. 

Removal  of  appendix ,  when  adherent  ;  to  cecum, 
579,  581,  582;  to  omentum,  583,  584;  to 
ovary,  72.5,  726;  to  tumor  of  uterus  or  ovary, 
728. 

Removal  of  appendix,  methods  for;  Beck's, 
560,  561;  Dawbarn's,  563,  564;  Deaver's, 
566,  567;  Edebohls's,  565,  566;  Fowler's, 
562,563;  Halsted's,  559 ;  Kelly's,  572;  Len- 
nander's,  575;  Morris's,  566;  Riedel's,  561, 
562;    Skene'-,  567. 

Removal  of  appendix,  operations  for;  atypical, 
575-594:    typical,  552  575 

Renal  complications  in  appendicitis.  403.  404. 

Renal  disease  mistaken  for  appendicitis,  421- 

424. 
Residual  appendicitis,  27s.  2S7.  288. 
Retrocecal  appendicitis,  587-589. 
Retrocecal  folds  and  fossse,  99-102. 

Retrocecal  glands,  enlargement    of,  420,  421. 
Retrocecal  position  of  appendix,  123.  127   130. 
Retrocolic   glands,   enlargement    of,   420.  421. 

Retrogression  of  appendix.   152  151. 

Retro-peritoneal  abscess,  314, 

Rigidity,  abdominal;  indication   for  operation, 

498;    symptom  of  appendicitis,  389  390 
Rigidity  of  appendix  in  chronic  appendicitis, 

279 


Saw  oma  of  appendix;  clinical  history  of,  7.57- 

760;   operation  for,  773,. 
Sedative-,  use  of,  after  operation,  6.57. 
Septicemia  as  a  complication  of  appendicitis, 

401. 
Severe  and   fatal   symptoms   after  operation, 

659,  660. 
Sex  iii  the  etiology  of  appendicitis,  358,  359, 

i:,:;. 

Shot    in   the  appendix.  372,  373. 

Skin   affections   as   a   post-operative  sequela, 

682. 
Spleen,  condition  of,  in  appendicitis  at  autopsy, 

246. 
Spoiitanei.il-   amputation    of   appendix,  470. 

Structure  of  appendix,  139  lis 

Subphrenic  abscess  in   appendicitis  214-225; 

complication,   402;    etiology   of,   636,   637; 

symptoms  of,  637.  638;   treatment  of,  038- 

641. 


INDEX. 


827 


Suppuration  of  abdominal  wound,  003,  004. 

Symptoms  of  acute  appendicitis;  chills,  394; 
constipation,  391;  distention  of  abdomen, 
3(17:  general  appearance,  398;  hemorrhage, 
391,  302;  jaundice,  397,  398;  muscle  spasm, 
390;  pain.  386  388;  pulse,  394,  39.5;  rigid- 
ity of  abdomen,  3s9.  39il;  tenderness,  3S8, 
389;  vomiting,  390,  391. 

Symptoms  of  appendicitis  in    child,  155-459. 

Symptom;;  of  chronic  appendicitis,  405,  406. 


Temperature,  elevation  of,  in  appendicitis; 
indication  for  operation,  498,  499;  symptom, 
392-394. 

Terminations  of  appendicitis,  199. 

Thrombosis,  of  appendical  vessels,  198,  329. 
330;  of  iliac  and  femoral  vessels,  332,  333; 
of  mesenteric  vessels,  330,  331. 

Toxicity  of  appendicitis,  198,  276-278. 

Transient  appendix,  .56-58. 

Trauma  in  etiology  of  appendicitis,  361,  362, 
455,  794-796,  805-806. 

Traumatic  appendicitis;  analysis  of,  804-806; 
cases  of.  770-803:  history  of,  794-790; 
medico-legal  complications  of,  806-S10. 

Tuberculosis  of  appendix;  at  autopsy,  251; 
clinical  history  of,  761-768;  pathology  of, 
336-342. 

Tuberculosis  of  peritoneum  ;  affecting  appendix 
by  contiguity.  196.  705:  mistaken  for  ap- 
pendicitis in  child,  463-481. 

Tumor  in  appendicitis:  indication  for  opera- 
tion, 499:    symptom,  39.5. 

Tumors  of  appendix.     See  Neoplasms. 

Typhlitis.     See  ('iriim,  primary  ulceration  of. 

Typhoid  fever,  appendicitis  in;  diagnosis  of, 
442-444:  etiology,  434,  43.5;  frequency  of, 
433,  434:  history  of.  432.  433:  operation 
for,  444-449. 

Typhoid  fever,  condition  of  appendix  in,  at 
autopsy.  251. 

Typhoid  fever,  diagnosis  between,  and  appen- 
dicitis, 440-443,  444,  459. 


Typhoid  fever  followed    by  appendicitis,  438, 

439. 
Typhoid  fever  following  appendicitis,  439.  110. 
Typhoid  legions  in  appendix,  348-352,435-438. 

UMBILIC  u.  hernia,  appendix  contained  in,  789. 

Umbilicus,  appendical  abscess  discharging  at, 
204. 

United  States:  development  of  appendical  sur- 
gery in,  47-52;  early  history  of  appendicitis 
in,  17-19,  22-24;  first  case  of  appendicitis 
in,  17. 

Ureters,  disease  of,  mistaken  for  appendicitis, 
421-423. 

Uric  acid  diathesis  in  etiology  of  appendicitis 
in  child,  455. 

Urinary  fistula  in  appendicitis;  pathology  of, 
318-320;   post-operative  sequela,  681,  6S2. 

Urinary  tract,  disease  of,  in  appendicitis, 
natural  history  of,  197. 

Urine,  examination  of,  after  operation,  659. 

Vagina;  appendical  abscess  discharging  into, 
204;  drainage  by,  in  pelvic  abscess,  629; 
examination  by,  in  appendicitis,  413. 

Veins  of  appendix,  166-169. 

Vertebral  disease  mistaken  for  appendicitis, 
427. 

Vesica]  complications  of  appendicitis,  403.  404. 

Vomiting  in  appendicitis:  indication  for  opera- 
tion, 499;  symptom,  390,  391;  sole  symp- 
tom in  child,  450. 

Vomiting,  symptom  of  diffuse  purulent  appen- 
dicitis, 643. 

Widai.  reaction  in  diagnosis  between  appen- 
dicitis and  typhoid  fever.  441. 

Width  of  appendix,   138,   139. 

Willard  Parker  operation.  34-36. 

Wound,  abdominal:  cancer  of,  667;  care  of, 
after  operation,  057.  658;  closure  of,  .538, 
539;  discharge  of  appendix  at,  202:  gan- 
grene of,  664;   suppuration  of,  063,  664. 


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